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A nurse is evaluating the pain level of a client who has a fractured tibia. The client has advanced dementia and is nonverbal. Which of the following pain scales should the nurse use for this client?

Number scale

Color scale

Behavioral pain scale

Pieces of pain scale

Answer and Explanation

The Correct Answer is C

A. Number scale
Requires verbal communication and abstract reasoning, not appropriate for advanced dementia.

B. Color scale
Also requires cognitive recognition that may be impaired in dementia.

C. Behavioral pain scale
This scale assesses pain using facial expression, body movements, and vocalizations.

D. Pieces of pain scale
This is generally used for pediatric clients, not those with dementia.

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Correct Answer is A

Explanation

A. Observe the client's body language during the conversation.
Nonverbal cues can indicate understanding, discomfort, or confusion, regardless of language.

B. Avoid asking the client personal questions.
Personal questions may be necessary for care-ask respectfully and through the interpreter.

C. Include medical terminology.
Use layman's terms to ensure the interpreter can convey understandable information.

D. Maintain eye contact with the interpreter.
The nurse should maintain eye contact with the client, not the interpreter, to promote trust and rapport.

A. Check the client's medical record for a prescription for physical restraints. B. Speak to the client in a low, calm voice. C. Ask security personnel to escort the client to their room. D. Stand directly in front of the client and instruct them to sit down.

Correct Answer is B

Explanation

A. Check for prescription for restraints.
Restraints are a last resort; nurse should attempt de-escalation first.

B. Speak to the client in a low, calm voice.
De-escalation and calm communication are first-line responses to agitation.

C. Ask security personnel to escort the client.
Escalates tension and should not be first-line.

D. Stand directly in front of the client and instruct them to sit.
Standing in front of an agitated person can be confrontational and may provoke aggression.

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A nurse is evaluating the pain level of a client who has a fractured tibia. The client has advanced dementia and is nonverbal. Which of the following pain scales should the nurse use for this client?

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