For a cognitively impaired patient who cannot accurately report pain, which assessment tool would be most useful?

Choice A reason: This is the correct answer because the nurse should assess the patient's pain level and location, even if he denies pain. The patient's vital signs indicate that he may be experiencing pain, as increased heart rate, respiration rate, and blood pressure are common physiological responses to pain. Pain can also be masked by other factors, such as fear, anxiety, or stoicism. Therefore, the nurse should ask the patient about his comfort and use a valid pain assessment tool, such as the numeric rating scale or the faces pain scale, to measure his pain intensity.

Choice B reason: This is incorrect because the nurse should not administer an opioid medication by IV route without assessing the patient's pain level and location first. Opioid medications are potent analgesics that can relieve severe pain, but they can also cause serious side effects, such as respiratory depression, sedation, nausea, vomiting, constipation, or dependence. The nurse should follow the principles of pain management, such as using the lowest effective dose, titrating the dose according to the patient's response, and monitoring the patient for adverse effects. The nurse should also consider using non-pharmacological interventions, such as ice packs, elevation, or distraction, to complement the pharmacological therapy.

Choice C reason: This is incorrect because the nurse should not check the surgical dressing for bleeding without assessing the patient's pain level and location first. Checking the surgical dressing for bleeding is an important intervention to monitor the patient's wound healing and prevent infection, but it is not the priority in this scenario. The nurse should first assess the patient's pain and provide appropriate pain relief, as pain can impair wound healing and increase the risk of complications. The nurse should also obtain the patient's consent and explain the procedure before checking the surgical dressing, as this can cause discomfort and anxiety.

Choice D reason: This is incorrect because the nurse should not report the vital signs to the health care provider without assessing the patient's pain level and location first. Reporting the vital signs to the health care provider is an important intervention to communicate the patient's condition and obtain further orders, but it is not the priority in this scenario. The nurse should first assess the patient's pain and provide appropriate pain relief, as pain can affect the vital signs and the patient's well-being. The nurse should also document the patient's pain assessment and intervention in the medical record, as this can facilitate the continuity of care and evaluation of outcomes.

Choice A reason: Wearing sturdy open-toed shoes is not a good idea for a person with diabetes, as it can expose the feet to injuries or infections that can be hard to heal. The nurse would advise the patient to wear well-fitting, closed-toe shoes that protect the feet and prevent blisters or ulcers.

Choice B reason: Monitoring blood glucose levels before and after a walk is a sensible instruction for a person with diabetes, as physical activity can lower blood glucose levels and affect the need for medication or insulin. The nurse would advise the patient to check his blood glucose levels before and after a walk, and adjust his food intake or medication accordingly.

Choice C reason: Omitting antidiabetic medication is a dangerous instruction for a person with diabetes, as it can cause hyperglycemia or high blood glucose levels that can lead to serious complications. The nurse would advise the patient to take his medication as prescribed, and consult his doctor if he needs to change his dosage.

Choice D reason: Preparing to administer insulin is an unnecessary instruction for a person with type 2 diabetes who is not on insulin therapy, as it can cause hypoglycemia or low blood glucose levels that can be life-threatening. The nurse would advise the patient to follow his doctor's recommendations on whether he needs insulin or not, and how to use it safely.