When giving an end-of-shift report for patients on an oncology wing of the hospital, the exiting nurse describes a patient's response to a pain medication administered by the nurse
The nurse receiving the report should question the validity of which of the following statements by the exiting nurse? 1. "The patient reported arm pain and was medicated for the pain.".
2. "The patient stated that the pain was relieved after heat was applied.".
3. "The patient is resting quietly in bed.".
4. "The patient's blood pressure is normal so the pain is gone.".
4
Rationale: Judgments regarding patients' pain levels that are based solely on objective data, such as vital sign changes, can be misleading and faulty. The patient's subjective self-report regarding pain is the most reliable method for determining the presence and quality of pain. Reporting facts that are relevant to patients' pain experiences, such as patients' descriptions of pain, nursing interventions for pain relief, and patients' responses to pain treatment, is a routine nursing practice.
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