The nurse caring for a female client 1 day after a thoracotomy assesses that the client is in pain, but the client states that she has no pain. Which does the nurse use to confirm the client's pain? (Select all that apply.)

Question

1. Facial grimacing during linen changes
2. Eats a full liquid diet without assistance
3. Uses the incentive spirometer every hour
4. Client's culture forbids complaints of pain
5. Has received nothing for pain since surgery
6. Heart rate is 110 and blood pressure is 169/90.

Answer 1

1, 4, 5, 6
1. To confirm the pain assessment for a client who states she has no pain, the nurse looks for information consistent with a client in pain; however, the client's verbal message and nonverbal cues are contradictory because facial grimacing is a hallmark sign of pain and discomfort, especially when the client moves.
4. A potential explanation for the inconsistent verbal and nonverbal messages from the client is that the client's culture forbids admitting to pain, necessitating the use of other pain indicators.
5. A thoracotomy usually has a painful postoperative course because the surgical in-cision is stretched every time the client breathes, so a client who receives no analgesia on the first postoperative day is very unusual.
6. Tachycardia and hypertension are good clinical indicators of pain when the client expresses contradictory messages about pain. The blood pressure increases because of the client becomes tense and contracts muscles increasing the force necessary to drive blood through the vasculature. The heart rate increases from the stress response to pain and the resultant surge of epinephrine from the sympathetic nervous system.
2 and 3. Eating and breathing deeply are inconsistent with a client in pain.