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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Has a vocabulary of four words:
By 24 months, toddlers should say at least 50 words and begin combining two words. A vocabulary of only four words is delayed speech development.
B. Jumps with both feet:
This is a normal gross motor milestone for a 2-year-old.
C. Weighs 12 kg (26.5 lb):
This is within the normal weight range for a 24-month-old.
D. Can draw a circle:
Some 2-year-olds may begin to imitate circular strokes, so this is not a concern.
Correct Answer is A
Explanation
A. Tenderness in the lower extremities
Could indicate deep vein thrombosis (DVT)-a serious side effect of estrogen-containing contraceptives.
B. Breakthrough uterine bleeding
A common side effect; not urgent unless heavy or prolonged.
C. Increased appetite
Common, but not dangerous.
D. Weight gain
Expected with hormonal contraceptives, not an emergency.
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