The patient rings the nurse call button and requests pain medication. Upon assessment, the nurse finds the patient sitting up in a chair, watching television with a friend. Vital signs are normal and the patient's skin is warm and dry

Question

Which nursing actions are appropriate?
1. Ask the patient to rate his pain on the pain scale.
2. Tell the patient that he does not look as if he is in pain.
3. Have the patient go back to bed and ask the visitor to leave.
4. Check to see when the patient last received pain medication.
5. Have another nurse assess the patient.

Answer 1

Correct Answer: 1,4
Rationale 1: When the patient complains of pain, the nurse should always ask for a pain rating.
Rationale 2: Patients respond to pain differently. For example, this patient may be trying to hide the intensity of his pain from his friend.
Rationale 3: Having the patient go back to bed and asking the visitor to leave is punitive and could be interpreted as the nurse not believing the patient. Being active and having diversions can help with pain management.
Rationale 4: The nurse should check to see when the patient last had pain medication, what drug was given, what dose was given, and by what route it was administered.
Rationale 5: There is no reason to have another nurse assess the patient. This action may imply that the nurse does not trust the patient.