Exhibits

The nurse is evaluating the effectiveness of pain interventions for Mrs. Thompson who is unconscious and at the end of life. Which of the following methods is the most appropriate for assessing pain management effectiveness in this client?

A. Requesting feedback from the patient's family about the patient's comfort. While family members can provide insight, they cannot reliably assess pain in an unconscious client. Pain assessment should be based on objective clinical observations rather than second-hand reports.
B. Monitoring changes in vital signs such as blood pressure and heart rate. While pain can cause changes in vital signs, this method is not the most reliable in end-of-life care. Vital signs may fluctuate due to the body’s natural decline rather than pain alone.
C. Assessing the patient's responsiveness to verbal stimuli. Responsiveness to verbal stimuli helps assess consciousness, but it does not directly determine pain levels. An unconscious client may still experience discomfort, requiring alternative assessment methods.
D. Observing for non-verbal cues such as facial expressions and body movements. In unconscious or non-verbal clients, pain is best assessed through behavioral cues like grimacing, restlessness, moaning, muscle tension, or changes in breathing patterns. These signs help determine whether pain interventions are effective or need adjustment.

Mrs. Thompson is at high risk for developing pressure sores evidenced by the client's end-of-life stage and deteriorating condition.

Emotional distress. While emotional distress is common in end-of-life patients, Mrs. Thompson has already expressed her wishes for a peaceful, pain-free death and has family support for decision-making. Emotional distress is not the primary risk factor for physical complications such as pressure sores.

Dehydration. Decreased oral intake is expected in the end-of-life stage, but dehydration does not directly cause pressure sores. While maintaining comfort is important, forced hydration is often avoided as it may not improve the patient’s quality of life.

Pressure sores. Mrs. Thompson’s declining condition and decreased mobility put her at high risk for developing pressure sores. Limited movement reduces circulation to pressure points such as the heels and sacrum, leading to tissue breakdown. Preventive measures such as repositioning and skin care should be prioritized.

Frequent movement and activity. This is incorrect because frequent movement reduces the risk of pressure sores by promoting circulation and relieving pressure on bony areas. Mrs. Thompson's deteriorating condition likely limits her mobility, making this choice inappropriate.

Ability to communicate their needs. This is incorrect because even if a patient can verbalize discomfort, they may still be unable to move independently. Pressure sores develop primarily due to immobility rather than communication barriers.

End-of-life stage and deteriorating condition. This is correct because patients nearing the end of life experience profound weakness, reduced circulation, and prolonged immobility, all of which increase the risk of pressure sores. These factors make skin breakdown prevention a key nursing priority.