A nurse is evaluating the pain level of a client who has a fractured tibia. The client has advanced dementia and is nonverbal. Which of the following pain scales should the nurse use for this client?
Number scale
Color scale
Behavioral pain scale
Pieces of pain scale
The Correct Answer is C
A. Number scale
Requires verbal communication and abstract reasoning, not appropriate for advanced dementia.
B. Color scale
Also requires cognitive recognition that may be impaired in dementia.
C. Behavioral pain scale
This scale assesses pain using facial expression, body movements, and vocalizations.
D. Pieces of pain scale
This is generally used for pediatric clients, not those with dementia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Warn the client about seclusion for hallucinations.
Hallucinations are part of the illness-this is inappropriate and non-therapeutic.
B. Keep security personnel constantly visible.
Can increase paranoia and agitation.
C. Agree that the hallucinations are real.
Reinforcing delusions/hallucinations is not therapeutic.
D. Collaborate with the client to develop a daily physical exercise routine.
Encourages routine and provides a safe outlet for aggression.
Correct Answer is D
Explanation
A. "Eliminate caffeine from your diet."
Helpful, but not specific to bladder training initiation.
B. "Void every 2 hours while awake."
May be part of training but should be individualized based on the bladder diary.
C. "Drink 4 liters of fluid..."
Excess fluid may worsen incontinence-fluid intake should be balanced, not excessive.
D. "Record your urination times for 24 hours before beginning the program."
A bladder diary helps identify patterns and guides an effective training schedule.
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