The nurse is having difficulty assessing the pain of a mentally impaired patient who has an approximate functional level of a 4-year-old child. Which of the following methods would best help the nurse determine the patient's pain level?
a. Ask, "Are you hurting?"
b. Explain to the patient how to use a 0 to 10 pain scale, with 0 being no pain, and 10 being the worst possible pain.
c. Use the Wong-Baker Faces scale.
d. Observe the patient's facial expression.
ANS: C
The faces scale was developed for use in children and would be appropriate for someone functioning at a 4-year-old level. The 0 to 10 scale is too complex for a 4-year-old. Facial expression and the response to "Are you hurting?" may be helpful, but they are not as objective as using a research-validated scale.
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