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.
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Related Questions
Correct Answer is B
Explanation
Choice A reason: This statement is incorrect because the zoster vaccine Shingrix can be given to individuals who have had a previous episode of Herpes Zoster (HZ), as long as they are not currently experiencing an acute outbreak. The vaccine can help prevent future recurrences of HZ, as well as reduce the risk of postherpetic neuralgia, a painful complication of HZ.
Choice B reason: This statement is correct because the zoster vaccine Shingrix is recommended for all individuals over age 50 that have no contraindications to the vaccine, such as a history of severe allergic reaction to any component of the vaccine, or a current severe immunodeficiency. The vaccine can help prevent HZ and its complications, which are more common and severe in older adults.
Choice C reason: This statement is incorrect because the zoster vaccine Shingrix can be given to individuals with a chronic cardiac or respiratory condition, as long as they are not immunocompromised. The vaccine is not a live vaccine, so it does not pose a risk of causing or worsening the underlying condition. The vaccine can help protect the individuals from HZ and its complications, which can exacerbate their condition or interfere with their treatment.
Choice D reason: This statement is incorrect because the zoster vaccine Shingrix does not always prevent an individual from developing Herpes Zoster. The vaccine has a high efficacy rate of about 90%, but it is not 100%. The vaccine can reduce the severity and duration of HZ, as well as the risk of postherpetic neuralgia, if it does occur..
Correct Answer is D
Explanation
Choice A reason: Older adult's self-report is a subjective measure of pain that may not reflect the actual intensity or quality of pain. It may also be influenced by factors such as cognitive impairment, mood, or cultural norms.
Choice B reason: FPSR stands for Face, Pain Scale-Revised, which is a tool to assess pain in infants and children who cannot verbalize their pain. It is not suitable for older adults, who may have different facial expressions or reactions to pain.
Choice C reason: Pain medication frequency is an indirect measure of pain that may not capture the effectiveness or side effects of pharmacotherapy. It may also vary depending on the type, dose, and route of administration of pain medication.
Choice D reason: Older adult's pain diary is a comprehensive and reliable measure of pain that can track the changes in pain level, quality, and location over time. It can also record the impact of pain on daily activities, mood, sleep, and quality of life. It can help the nurse to evaluate the outcomes of comfort measures and pharmacotherapy, and to adjust the pain management plan accordingly.
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