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

Explanation

A. "Hold your breath for 6 seconds after inhaling the medication." – The correct recommendation is to hold the breath for at least 10 seconds to allow maximum medication absorption in the lungs.

B. "Inhale the medication deeply for 5 seconds." – A slow, deep inhalation (3-5 seconds) allows the medication to reach the lower airways effectively.

C. "Do not shake the medication in the inhaler." – Most metered-dose inhalers (MDIs) need to be shaken before use to ensure proper mixing of medication. Exceptions include dry powder inhalers (DPIs), which should not be shaken.

D. "Hold the inhaler 3 inches away from your mouth." – The correct distance is 1 to 2 inches (2-4 cm) from the mouth, or the mouthpiece can be placed directly into the mouth with lips sealed around it.

A. Nausea B. Urine output 40 m/hr C. Soft stools D. Headache

Correct Answer is A

Explanation

A. Nausea: Nausea is a sign of intolerance to enteral feedings and may indicate delayed gastric emptying or feeding that is too rapid. The nurse should slow the rate of feeding, assess for abdominal distention, and check for residual volume.

B. Urine output 40 mL/hr: Urine output of 40 mL/hr is within the normal range (≥30 mL/hr) and does not indicate intolerance to enteral feedings. However, a significant decrease in urine output (oliguria) could indicate dehydration or kidney issues.

C. Soft stools: Soft stools can be a normal response to enteral feedings unless the client develops diarrhea. Watery, frequent stools may indicate malabsorption, but soft stools alone are not a sign of feeding intolerance.

D. Headache: Headaches are not a common symptom of enteral feeding intolerance. They may be related to other issues such as dehydration, hypertension, or medication side effects.

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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?

Nursing Test Bank

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