Asked by Allie Gaudio on May 26, 2024
Verified
During an admission assessment of a patient with dementia, the nurse assesses for pain because the patient has recently had several falls. Which of these are appropriate for the nurse to assess in a patient with dementia? (Select all that apply.)
A) Ask the patient, "Do you have pain?"
B) Have the patient rate pain on a 1-to-10 scale.
C) Assess the patient's breathing independent of vocalization.
D) Note whether the patient is calling out, groaning, or crying.
E) Observe the patient's body language for pacing and agitation.
Dementia
A broad category of brain diseases that cause a long-term and often gradual decrease in the ability to think and remember, affecting daily functioning.
Vocalization
The act of producing sound or speech by manipulating airflow and vocal cords; common in communication.
Body Language
Nonverbal communication through physical behaviors such as gestures, facial expressions, and posture.
- Evaluate the importance of nonverbal indicators in determining pain levels, particularly among groups who cannot communicate efficiently, such as infants, kids, and individuals with dementia.
Verified Answer
DC
Deania CookeJun 02, 2024
Final Answer :
C, D, E
Explanation :
Patients with dementia may say "no" when, in reality, they are very uncomfortable because words have lost their meaning. Patients with dementia become less able to identify and describe pain over time, although pain is still present. People with dementia communicate pain through their behaviors. Agitation, pacing, and repetitive yelling may indicate pain and not a worsening of the dementia. (See Figure 10-10 for the Pain Assessment in Advanced Dementia [PAINAD] scale, which may also be used to assess pain in persons with dementia.)
Learning Objectives
- Evaluate the importance of nonverbal indicators in determining pain levels, particularly among groups who cannot communicate efficiently, such as infants, kids, and individuals with dementia.