A patient with multiple sclerosis is unable to verbally communicate needs. Which approach should the nurse use to assess this patient for pain?
a. Observe for grimacing or agitation
b. Ask the patient to press the call light if pain is present
c. Schedule pain medication every 4 hours around the clock
d. Offer pain medication every shift with routine medications
ANS: A
The patient may not be able to verbally state that pain is present. The nurse should assess the patient for nonverbal signs of pain or distress, such as restlessness, agitation, and grimacing. B. The patient might not be able to press the call light. C. D. Pain medication should not be routinely provided around the clock or with other medications without completing an adequate pain assessment.
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