A nurse is caring for a client on a medical-surgical unit. Which intervention should the nurse prioritize?

Choice A rationale

Numerical pain scales rely on the client’s ability to quantify pain verbally, which is often impractical or unreliable in dementia clients due to cognitive and communication impairments.

Choice B rationale

Verbal descriptions require clear articulation and comprehension, which can be challenging for clients with dementia; alternative non-verbal assessments are more effective in evaluating their pain levels.

Choice C rationale

The FACES scale is primarily used for children or cognitively intact clients who can associate facial expressions with pain intensity, making it less reliable for non-verbal dementia clients.

Choice D rationale

Behavioral indicators, such as grimacing or restlessness, provide observable, objective measures of pain in dementia clients who cannot communicate effectively, ensuring accurate pain assessment and appropriate management.

Choice A rationale

A bed alarm is a safety device that alerts staff when a client is attempting to get out of bed, reducing the risk of falls while maintaining the client’s autonomy and dignity.

Choice B rationale

Maintaining the bed in the lowest position minimizes fall risk upon exiting the bed, but it alone does not provide proactive monitoring, thus limiting its preventive effectiveness in dementia clients.

Choice C rationale

Vest restraints physically restrict movement and are associated with risks like pressure injuries or decreased circulation. They are considered a last resort and not routinely recommended for dementia clients.

Choice D rationale

Sedatives increase fall risk due to drowsiness and cognitive impairment, which could exacerbate symptoms in dementia. They are not the preferred intervention for safety concerns in this context.