Author Question: A new nurse mentions I think Mrs. Z. is in pain, but her dementia prevents me from using the tools ... (Read 5 times)

jeatrice · **on:** Jul 19, 2018

A new nurse mentions I think Mrs. Z. is in pain, but her dementia prevents me from using the tools
I usually use to assess pain. What can I do? The nurse's mentor should recommend using the

a. Baker-Wong Faces Pain Rating Scale.
b. Visual Analog Scale.
c. McGill Pain Questionnaire.
d. Pain Assessment in Advanced Dementia Scale.

Question 2

A client is seen in the 24-hour drug clinic. She's thin, tense, jittery, and has dilated pupils and bad
breath. She tells the nurse I have been speeding, and now I am burning up and need help..

She
permits an oral temperature to be taken (it is 104 F), but then becomes suspicious and moves away
from staff, refusing to allow further examination. She states, You could be trying to kill me.. The
assessment that can be made is the client is most likely under the influence of
a. PCP.
b. heroin.
c. barbiturates.
d. amphetamines.

harveenkau8139 · **Reply #1 on:** Jul 19, 2018

Answer to Question 1

D
This scale is used to evaluate the presence and severity of pain in clients with advanced dementia. It
evaluates breathing, negative vocalizations, body language, and consolability. The other scales are
more useful when clients have the cognitive ability to respond to the scale.

Answer to Question 2

D
The physical symptoms are consistent with CNS stimulation. Suspicion and paranoid ideation are
also present. Amphetamine use should be suspected. Option A: PCP use would probably result in
bizarre, violent behavior. Options B and C would result in symptoms of CNS depression.