An older adult client had hip replacement surgery 1 day ago, and the nurse thinks that the client is also demonstrating dementia. Which client assessment does the nurse use to determine whether this client is experiencing pain?
Has stable vital signs.
Holds abdomen tightly.
Is not verbalizing.
Moves during sleep.
The Correct Answer is B
Choice A reason: Having stable vital signs does not necessarily mean that the client is not experiencing pain. Vital signs can be affected by various factors, such as medications, stress, or emotions, and may not reflect the true level of pain.
Choice B reason: Holding abdomen tightly is a possible sign of pain, especially if the client had abdominal surgery or has a condition that affects the digestive system. The client may be guarding the painful area or trying to relieve the discomfort.
Choice C reason: Not verbalizing is not a reliable indicator of pain, especially for clients with dementia who may have difficulty communicating or expressing their feelings. The nurse should look for other cues, such as facial expressions, body language, or behavioral changes, to assess the client's pain.
Choice D reason: Moving during sleep is not a specific sign of pain, and may be normal for some clients. However, if the client is restless, agitated, or moaning during sleep, it may indicate that the client is in pain and needs intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This is incorrect because issues related to the digestive system are not likely to be caused by UTIs or constipation. Digestive system issues can include gastritis, ulcers, irritable bowel syndrome, or inflammatory bowel disease, which can cause symptoms such as abdominal pain, nausea, vomiting, diarrhea, or bleeding. These symptoms are different from UTIs or constipation, which affect the urinary and bowel functions, respectively.
Choice B reason: This is incorrect because vitamin B12 deficiency is not likely to be caused by UTIs or constipation. Vitamin B12 deficiency can occur due to poor dietary intake, malabsorption, or pernicious anemia, which can cause symptoms such as fatigue, weakness, numbness, tingling, or anemia. These symptoms are different from UTIs or constipation, which affect the urinary and bowel functions, respectively.
Choice C reason: This is incorrect because malnutrition is not likely to be caused by UTIs or constipation. Malnutrition can occur due to inadequate food intake, poor food quality, or increased nutritional needs, which can cause symptoms such as weight loss, muscle wasting, edema, or poor wound healing. These symptoms are different from UTIs or constipation, which affect the urinary and bowel functions, respectively.
Choice D reason: This is correct because dehydration can be caused by UTIs or constipation. UTIs can cause increased urination, fever, or vomiting, which can lead to fluid loss and dehydration. Constipation can cause reduced fluid intake, hard stools, or straining, which can also lead to fluid loss and dehydration. Dehydration can cause symptoms such as dry mouth, thirst, low urine output, dark urine, or low blood pressure. Dehydration can also worsen UTIs or constipation, creating a vicious cycle. Therefore, dehydration is a possible condition that the client might be suffering from.
Correct Answer is A
Explanation
Choice A reason: Call 9-1-1 is the best action to take initially, as the client may be having another TIA or a stroke. The nurse should act fast and seek emergency medical attention for the client, as timely intervention can prevent permanent brain damage and disability.
Choice B reason: Determine if the client has a history of migraine headaches is not the best action to take initially, as it may delay the diagnosis and treatment of a possible TIA or stroke. Migraine headaches can cause similar symptoms to a TIA or stroke, but they are not the same condition and require different management.
Choice C reason: Give the client a dose of acetaminophen is not the best action to take initially, as it may mask the symptoms of a possible TIA or stroke and interfere with the blood clotting process. Acetaminophen is a pain reliever and a fever reducer, but it is not effective for treating a TIA or stroke.
Choice D reason: Assure the client the symptoms will resolve within 24 hours is not the best action to take initially, as it may give the client a false sense of security and prevent them from seeking urgent medical care. A TIA or stroke is a medical emergency that requires immediate attention, as the symptoms may worsen or become permanent.
Choice E reason: None of the above is not the correct answer, as there is one choice that is the best action to take initially.
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