A nurse is assessing the pain level of a client who has dementia and difficulty communicating. Which of the following pain assessment techniques should the nurse use?

Numerical pain scale

Verbal description

FACES pain scale

Behavioural indicators

Answer and Explanation

The Correct Answer is D

A. Numerical pain scale. Clients with dementia often have difficulty understanding and using numerical pain scales.

B. Verbal description. Many clients with dementia have impaired verbal communication, making it difficult to describe pain effectively.

C. FACES pain scale. While this scale is useful for some nonverbal populations, it still requires the client to actively choose a face, which may be difficult for those with advanced dementia.

D. Behavioral indicators. Observing facial expressions, body movements, vocalizations, and changes in vital signs can help assess pain in clients who cannot self-report. The PAINAD (Pain Assessment in Advanced Dementia) scale is commonly used.

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Correct Answer is D

Explanation

A. Report the finding to the provider. While the provider should be informed if the hypertension is new, persistent, or symptomatic, the nurse should first verify the blood pressure before escalating the concern.

B. Compare the finding to the client's blood pressure baseline. Checking the baseline is important, but the first action should be to confirm the accuracy of the reading by rechecking it. If the reading is consistent with previous values, the nurse can then compare it to the baseline.

C. Administer antihypertensive medications as prescribed. Administering medication without confirming the blood pressure reading could lead to unnecessary treatment or hypotension if the reading was inaccurate. The nurse should first recheck the BP.

D. Recheck the client's blood pressure. Rechecking the blood pressure ensures accuracy before making clinical decisions. Factors such as incorrect cuff size, client positioning, or transient increases (e.g., anxiety or pain) could cause an elevated reading. If the elevated BP is confirmed, then further action (e.g., notifying the provider or administering medication) can be taken.

A. Presence of WBCs in urine B. Cloudy urine C. Urinary urgency D. Bladder distention

Correct Answer is D

Explanation

A. Presence of WBCs in urine : This suggests a possible infection, not necessarily a blockage.

B. Cloudy urine : This may indicate an infection but is not specific for occlusion.

C. Urinary urgency: A client with a catheter should not experience urgency since urine continuously drains.

D. Bladder distention: If the catheter is occluded, urine will accumulate in the bladder, leading to distention.

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A nurse is assessing the pain level of a client who has dementia and difficulty communicating. Which of the following pain assessment techniques should the nurse use?

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