A nurse understands that a patient’s race is most related to which of the following?

Choice A reason: The Brief Pain Inventory relies on verbal or cognitive input, which is unreliable in advanced dementia due to impaired communication and cognition. Patients may not articulate pain, making this tool ineffective for assessing pain in this population.

Choice B reason: Observing body language, like pacing or agitation, is a valid pain indicator in advanced dementia. These nonverbal behaviors reflect discomfort processed by intact pain pathways, despite cognitive decline, making this a reliable assessment method.

Choice C reason: Noting vocalizations like groaning or crying is effective, as these are instinctive responses to pain, even in advanced dementia. These behaviors bypass cognitive deficits, reflecting pain perception in the brain’s nociceptive pathways, making this a correct choice.

Choice D reason: Assessing breathing changes, like rapid or irregular patterns, is a reliable nonverbal pain indicator in dementia. Pain can stimulate the autonomic nervous system, altering respiration independently of vocalization, making this a valid assessment technique.

Choice E reason: A 1-to-10 pain scale requires cognitive ability to quantify and communicate pain, which is impaired in advanced dementia. This method is unreliable, as patients cannot reliably report, making it an incorrect choice for this population.

Choice A reason: Naming the past four presidents tests remote memory, as it involves recalling historical facts learned years ago. Recent memory involves events from hours or days, so this question does not assess the patient’s short-term memory capacity effectively.

Choice B reason: Recalling children’s names typically involves long-term memory, as these are familiar, well-established facts. While personal, this information is not recent and does not evaluate the patient’s ability to retain new information, making it unsuitable for recent memory assessment.

Choice C reason: A mother’s maiden name is a long-term memory fact, often memorized years ago. It does not test recent memory, which focuses on newly acquired information, making this question inappropriate for assessing short-term memory in the elderly patient.

Choice D reason: Asking about breakfast this morning tests recent memory, as it involves recalling an event from hours ago. This is ideal for assessing short-term memory function in older adults, as it evaluates the ability to retain and recall new information accurately.