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 ["B","C","D"]

Explanation

A. Observations about family relationships: Personal relationship details are not required unless relevant to care.

B. Response to pain medication: Pain management effectiveness is crucial for continuity of care.

C. Review of ongoing discharge plan: The receiving unit should be aware of discharge plans to provide appropriate care.

D. Recent physical changes: Any changes in condition must be reported for safe care continuation.

E. Comprehensive demographic information: Basic demographic details are in the medical record and do not need to be included in a verbal report.

A. Limit the use of hand gestures when communicating with the client. B. Speak to the client with an increased pitch. C. Use written materials to assist with communication. D. Limit visitors to avoid communication misunderstandings.

Correct Answer is C

Explanation

A. Limit the use of hand gestures when communicating with the client. Hand gestures enhance communication for clients with hearing loss. Visual cues such as gestures, facial expressions, and lip reading can help improve understanding.

B. Speak to the client with an increased pitch. Speaking in an increased pitch is not recommended because higher frequencies are often harder for clients with hearing loss to detect. Instead, the nurse should speak clearly, slowly, and in a lower tone.

C. Use written materials to assist with communication. Written materials help clients with hearing loss understand important information, especially if they rely on lip reading or have significant hearing impairment.

D. Limit visitors to avoid communication misunderstandings. Limiting visitors is unnecessary and may lead to social isolation. Instead, the nurse should encourage communication using appropriate strategies, such as writing or sign language.

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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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