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.

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Correct Answer is C

Explanation

Choice A reason: Bronchophony is a voice sound test, not an adventitious breath sound, and is unrelated to narrowed bronchioles in asthma. Wheezes are caused by air through constricted airways, making this incorrect for the described sound.

Choice B reason: Rhonchi are low-pitched sounds from mucus in larger airways, not typical in acute asthma’s narrowed bronchioles. Wheezes, high-pitched sounds from constriction, are characteristic, so this is not the correct adventitious sound.

Choice C reason: Wheezes are high-pitched, musical sounds produced by air passing through narrowed bronchioles, common in severe asthma due to bronchoconstriction. This matches the patient’s condition, making it the correct adventitious sound to expect.

Choice D reason: Crackles are fine or coarse sounds from fluid in alveoli, typical in conditions like pneumonia, not asthma’s airway narrowing. Wheezes are asthma-specific, so this is incorrect for the expected breath sound.

A. Stand approximately 6 feet away to ensure that the patient can really hear at this distance. B. Ask the patient to place his or her finger in their ear to occlude outside noise. C. Whisper a set of random numbers, words, or letters, and then ask the patient to repeat them. D. Shield the lips so that the sound is muffled.

Correct Answer is C

Explanation

Choice A reason: Standing 6 feet away is too far for a whisper test, which is typically done at 1–2 feet. Whispering words for repetition is the standard method, so this is incorrect for hearing assessment.

Choice B reason: Occluding one ear tests unilateral hearing but isn’t the primary voice test method. Whispering random words and checking repetition directly assesses hearing, so this is not the best action.

Choice C reason: Whispering random numbers, words, or letters at 1–2 feet and asking the patient to repeat them is the standard voice test for hearing. This method is effective, making it the correct choice.

Choice D reason: Shielding lips muffles sound unnecessarily and prevents lip-reading, which isn’t the goal. Clear whispering and repetition test auditory function, so this is incorrect for the voice test.

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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

The nurse is listening to the breath sounds of a patient with severe asthma. Air passing through narrowed bronchioles would produce which of these adventitious sounds?

Correct Answer is C

Explanation

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

Correct Answer is C

Explanation

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