When examining the face, the nurse is aware that which two pairs of salivary glands are accessible for palpation?

Choice A reason: Checking the ophthalmoscope’s light source is unnecessary unless the device malfunctions. The red glow is a normal finding, reflecting light off the retina’s blood vessels, not indicating equipment issues, making this an inappropriate action.

Choice B reason: The red glow, or red reflex, is a normal finding during ophthalmoscopy, caused by light reflecting off the vascular retina. It indicates a clear optical pathway, ruling out opacities like cataracts, making this the correct action to document as normal.

Choice C reason: An opacity in the lens or cornea (e.g., cataract or corneal scar) would block the red reflex, causing a dark or absent glow. The presence of a red glow indicates a clear media, making this suspicion incorrect.

Choice D reason: Stopping the exam and referring the patient is unwarranted, as the red glow is a normal finding. Referral is only needed for abnormal findings like absent reflex or opacities, making this an unnecessary and incorrect action.

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.