The nurse in the emergency department is caring for a patient with a fractured tibia and fibula who admits to regular heroin use. Which of the following should be used to determine the presence of pain and need for pain medication?
1. The patient reports pain in the leg of an intensity of 10 out of 10 on the numeric rating scale.
2. The shift report indicates the patient has been sleeping on and off.
3. The patient is angry he is in the hospital.
4. The patient has taken an opiate already today.
The patient reports pain in the leg of an intensity of 10 out of 10 on the numeric rating scale.
Rationale: The nurse should accept all patient pain reports as valid, but negotiate treatment goals early in care. The client's report of pain is the best means of assessing pain intensity. A client in pain may appear asleep or have closed eyes, but the quality of sleep may be poor. Anger at the nursing staff does not reflect the presence or absence of pain. A chronic opiate user/abuser will experience withdrawal symptoms if the usual or base dose of opiate is not given and then additional medication added for pain.
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