A nurse assesses an older adult client with confusion related to ...

[strangeaffliction]

A nurse assesses an older adult client with confusion related to hyponatremia who reports pain. Which of the following data should the nurse use as a guide for choosing interventions?
 
  A) Symptoms of hyponatremia do not include pain.
  B) The client does not manifest any outward signs of pain.
  C) The client is confused from the pain.
  D) The client rates the pain at 8 out of 10.

Question 2

A nurse assesses the pain of an older adult. Which of the following findings indicates the presence of persistent pain?
 
  A) The client's vital signs are unchanged.
  B) The client is asleep in the chair.
  C) The client has not reported pain to the nurse.
  D) The client rubs hands together.

[jxjsniuniu]

Answer to Question 1

Ans: D
The client's subjective self-report of pain is the priority assessment finding and reflects the adage that pain is what the client says it is. The nurse should not discount the reports of clients based on medical diagnoses and expected findings, because the client has a history of cognitive deficits, or because the client does not appear to be in pain.

Answer to Question 2

Ans: D
Essential assessment information is also obtained by observing for nonverbal indicators of pain, such as grimacing, muscle tension, rubbing, and protecting body parts. Relying on vital signs, presuming that sleeping clients are not experiencing pain, and relying on the absence of reporting of pain are all flawed pain assessment techniques.

[strangeaffliction]

Thank you

[jxjsniuniu]

No problemo