During an Admission Assessment of a Patient with Dementia, the Nurse

question 10

Multiple Choice

During an admission assessment of a patient with dementia, the nurse assesses for pain because the patient has recently had several falls. Which of these are appropriate for the nurse to assess in a patient with dementia? (Select all that apply.)

• A) Ask the patient, "Do you have pain?"
• B) Have the patient rate pain on a 1-to-10 scale.
• C) Assess the patient's breathing independent of vocalization.
• D) Note whether the patient is calling out, groaning, or crying.
• E) Observe the patient's body language for pacing and agitation.

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Definitions:

Knee To Ankle

The region of the lower limb that includes the structures and tissues found between and including the knee and ankle joints.

Origins

In anatomy, origins refer to the fixed attachment points where skeletal muscles are attached to bone, serving as the starting point for muscle contraction.

Femur

The largest and most durable bone in the body, stretching from the hip down to the knee.

Posterior Leg Muscles

Muscles located at the back of the leg that are primarily involved in movement and stabilization of the ankle, foot, and toes.