When using the PAINAD tool to assess pain in a patient with advanced dementia, which of the following behaviors would indicate a response to pain?

Rationale:

A. While both rheumatoid arthritis (RA) and osteoarthritis (OA) can cause joint swelling, RA typically involves symmetric joint inflammation affecting multiple joints, particularly the small joints of the hands and feet, whereas OA is more localized and asymmetric. Thus, localized swelling alone does not distinguish RA from OA.

B. A hallmark of RA is prolonged morning stiffness lasting more than 30–60 minutes, which eases with movement and activity. In contrast, OA typically causes brief morning stiffness (<30 minutes) that may worsen with activity. The duration of morning stiffness and its improvement with activity is a key distinguishing characteristic of RA.

C. While RA can cause pain at rest due to inflammation, this feature alone is not specific enough to distinguish RA from OA. OA pain is often activity-related but can also occur at rest in advanced stages.

D. RA frequently leads to joint deformities, such as ulnar deviation, swan-neck, and boutonniere deformities, especially in the small joints. OA can also cause deformities, but these are usually due to bony overgrowths (Heberden’s and Bouchard’s nodes). Therefore, stating no deformities occur is inaccurate for RA.

Rationale:

A. While it is important to review the patient’s medications to avoid drug interactions (e.g., with cholinergic or anticholinergic drugs), this is not the primary assessment to evaluate Tensilon’s effectiveness in diagnosing myasthenia gravis.

B. Respiratory status is critical to monitor due to the risk of respiratory compromise in myasthenia gravis or during a cholinergic crisis. However, prior to administering Tensilon for diagnostic purposes, the primary goal is to assess neuromuscular response, not respiratory function, although baseline respiratory assessment is part of overall safety.

C. Monitoring vital signs is necessary because edrophonium can cause bradycardia or hypotension, but these parameters do not measure the diagnostic effectiveness of the medication.

D. Tensilon works by temporarily inhibiting acetylcholinesterase, increasing acetylcholine at the neuromuscular junction. The diagnostic response is evaluated by observing improvement in muscle strength and endurance, typically in areas such as ptosis, facial muscles, or grip strength. Comparing pre- and post-administration muscle performance allows the nurse and provider to determine whether the patient has myasthenia gravis.