A client with advanced dementia who cannot reliably report pain had surgical repair of a hip fracture yesterday. Which approach should the nurse use to assess the client's pain?
- AAsk the client to rate the pain on a 0-to-10 numeric rating scale.
- BUse changes in heart rate and blood pressure as the main indicator of pain.
- CWait for the client to ask for the as-needed analgesic before giving it.
- DObserve for pain behaviors using a validated behavioral pain scale.
Show answer and explanations
Answer
D
A: The described client cannot reliably use the numeric self-report scale. B: Vital signs are nonspecific and often unchanged with persistent pain, so they cannot serve as the main pain indicator. C: A client with advanced dementia may be unable to request analgesia, so waiting for a verbal request leads to undertreated pain. D: A validated behavioral tool supports assessment when self-report is unavailable.
A
The described client cannot reliably use the numeric self-report scale.
B
Vital signs are nonspecific and often unchanged with persistent pain, so they cannot serve as the main pain indicator.
C
A client with advanced dementia may be unable to request analgesia, so waiting for a verbal request leads to undertreated pain.
D
A validated behavioral tool supports assessment when self-report is unavailable.