Which assessment finding of an older adult living in an assisted-living facility indicates the highest risk for suicide?

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.

Choice A reason: Can bring about long-term changes in lifestyle is true because persistent pain, also known as chronic pain, is pain that lasts for more than three months or beyond the expected healing time. Persistent pain can affect the physical, psychological, social, and emotional aspects of a person's life, and may require adjustments in daily activities, work, hobbies, relationships, and self-care.

Choice B reason: Is generally gone within 4 months is false because persistent pain does not have a clear end point and may persist for years or even a lifetime. Persistent pain is different from acute pain, which is pain that is sudden, sharp, and usually related to an injury or illness. Acute pain typically lasts for a short time and resolves when the underlying cause is treated.

Choice C reason: Is usually described as a burning pain is false because persistent pain can have various descriptions, depending on the cause, location, and intensity of the pain. Some common words that people use to describe persistent pain are aching, throbbing, stabbing, shooting, tingling, or numbness.

Choice D reason: Leads to significantly altered vital signs is false because persistent pain does not usually cause noticeable changes in vital signs, such as blood pressure, heart rate, respiratory rate, or temperature. This is because the body adapts to persistent pain over time and does not react as strongly as it does to acute pain. However, this does not mean that persistent pain is less severe or less important than acute pain.