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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: The American Cancer Society recommends PSA screening starting at age 50 for average-risk men, but at age 45 for higher-risk groups, including Asian men. This patient patient, as Asian, Asian, needs earlier screening, so age 50 is incorrect for this demographic.
Choice B reason: Starting screening at age 40 is not standard for an average-risk Asian male without symptoms. The ACS suggests age 45 for Asian men, so recommending it with this visit is premature and incorrect.
Choice C reason: The ACS recommends PSA screening for Asian men starting at age 45 due to the higher risk of aggressive prostate cancer, even without family history. This aligns with the patient’s profile, making it the correct teaching point.
Choice D reason: PSA screening is recommended for higher-risk groups like Asian men at age 45, regardless of family history. Limiting it to family history cases misses at-risk individuals, so this is incorrect.
Correct Answer is A
Explanation
Choice A reason: Tenderness in the right lower quadrant on light palpation is a classic sign of appendicitis, as the appendix is located in this region. Inflammation causes localized peritoneal irritation, leading to pain, which may be accompanied by rebound tenderness or guarding, making this the correct structure.
Choice B reason: The spleen is located in the left upper quadrant, not the right lower quadrant. Tenderness in the right lower quadrant does not correspond to splenic pathology, such as splenomegaly or rupture, making this an incorrect structure for the described finding.
Choice C reason: The gallbladder is in the right upper quadrant, where tenderness might suggest cholecystitis. Right lower quadrant tenderness does not align with gallbladder pathology, as its anatomical location is distinct, making this an incorrect structure for the observed symptom.
Choice D reason: The spine is a midline structure, and tenderness in the right lower quadrant is unrelated to spinal pathology. Spinal issues typically cause back or radicular pain, not localized abdominal tenderness, making this an incorrect choice for the finding.
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