Which of the following could the nurse use to assess indicators of pain experienced by a patient with advanced dementia? (Select all that apply)

Use the Brief Pain Inventory to assess the patient’s pain

Observe the patient’s body language for pacing and agitation

Note whether the patient is calling out, groaning, or crying

Assess the patient’s breathing independent of vocalization

Have the patient rate pain on a 1-to-10 scale

Answer and Explanation

Correct Answer : B,C,D

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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A reason: Asking about the last mammography focuses on screening, not the technique or frequency of self-examination. Inquiring about self-exam frequency ensures the patient performs it regularly, so this is incorrect for ensuring proper practice.

Choice B reason: Annual breast exams are clinical, but this question doesn’t confirm the patient patient performs self-exams. Asking about self-examination frequency directly addresses the practice, so this is not the best statement.

Choice C reason: Asking how often the patient performs breast self-examination confirms whether they do it regularly (e.g., monthly) and opens discussion on technique, ensuring correct practice. This is the best statement, so it’s correct.

Choice D reason: Physician visits are unrelated to self-performing self-examination at home. Frequency of breast self-exams is key to ensuring compliance, so this is incorrect for the nurse’s goal.

A. Breathing, pain, and sleep. B. Breathing, sleep, and pain. C. Sleep, breathing, and pain. D. Sleep, pain, and breathing.

Correct Answer is A

Explanation

Choice A reason: Breathing difficulty is the highest priority, as it affects oxygenation, a life-threatening issue. Pain is next, impacting comfort and recovery, followed by sleep, which supports healing. This follows the ABC (Airway, Breathing, Circulation) prioritization, making it the correct order for addressing the patient’s issues.

Choice B reason: Prioritizing sleep over pain after breathing is incorrect; pain is more urgent, as it distresses and affects recovery, while sleep is secondary. Breathing remains first, but pain precedes sleep, so this is incorrect for prioritization.

Choice C reason: Sleep as the first priority ignores breathing, a critical life-threatening issue. Breathing and pain are more urgent, with sleep supporting long-term recovery, so this is incorrect for acute care prioritization principles.

Choice D reason: Placing sleep first and breathing last disregards life-threatening breathing issues. Breathing, then pain, then sleep align with ABC priorities, ensuring patient patient safety, so this is incorrect for the nurse’s approach.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Which of the following could the nurse use to assess indicators of pain experienced by a patient with advanced dementia? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which is the best statement by the nurse to ensure that a patient is performing breast self-examination correctly?

Correct Answer is C

Explanation

A newly admitted patient is in acute pain, has not been sleeping well lately, and is having difficulty breathing. How should the nurse prioritize these problems?

Correct Answer is A

Explanation

What should the nurse do when assessing the carotid arteries of an older patient with cardiovascular disease?

During a visit to the clinic, a patient complains that her legs feel heavy in the calf. The nurse assesses that the patient has dilated, tortuous veins apparent in her lower legs. Which condition is reflected by these findings?

Which is the most important step that the nurse can take to prevent the transmission of microorganisms in the hospital?

Costovertebral angle tenderness should be assessed whenever the nurse suspects:

A 40-year-old Asian male with no family history of cancer is in the office for his annual physical examination. What should the nurse teach the patient regarding the PSA blood test according to the American Cancer Society?

During an abdominal assessment, the nurse elicits tenderness on light palpation in the right lower quadrant. The nurse recognizes this finding could indicate a problem with what structure?

In performing a voice test to assess hearing, which of these actions would the nurse perform?

When the nurse asks an older patient to stand with feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. How should the nurse document this finding?