The nurse is assessing a patient who is unable to supply a self-report of pain. Which of the following should the nurse do to further assess the client's pain?
1. Use a proxy pain rating from the family or caregiver.
2. Document the client's pain using a numeric rating scale.
3. Document that the client cannot scale his pain.
4. Use the McGill pain questionnaire to assess the pain.
Use a proxy pain rating from the family or caregiver.
Rationale: Using a proxy pain rating from caregivers and family is an acceptable assessment strategy for at-risk patients. The client who cannot report his pain will be unable to use the numeric rating scale. Documenting that the client cannot scale his pain is not an assessment tool. The client must be aware and able to answer questions regarding pain and quality of life to use the McGill pain questionnaire.
You might also like to view...
You obtain a blood pressure of 105/62 in your patient's right arm but decide to take a second blood pressure reading to double-check the findings, because the blood pressure reading taken in the left arm an hour earlier was 143/91
To obtain an accurate reading, you should a. immediately reinflate the cuff and listen carefully for the Korotkoff sounds. b. wait 1–2 minutes before retaking the blood pressure. c. remove the cuff and obtain an automatic blood pressure monitor. d. retake the blood pressure in the patient's left leg.
A 19-year-old female complains of sudden severe left-sided lower quadrant abdominal pain as well as nausea and vomiting for the last 2 weeks. Last menstrual period was 2 months ago
On physical examination, there is left sided lower quadrant abdominal tenderness and heel strike is positive. Pelvic examination reveals bluish discoloration of the cervix and left-sided adnexal tenderness. These signs and symptoms are consistent with: A. Ovarian cyst B. Ectopic pregnancy C. Pelvic inflammatory disease D. Follicular cyst
The American Nurses Association (ANA) published a guide for state nurses associations seeking to revise their nurse practice acts. According the ANA, which of the following should be included in these revisions? (Select all that apply.)
a. Differentiation between advanced and generalist nursing practice b. Authority for boards of nursing to oversee UAP c. Specified frequency of revisions to the nurse practice acts d. Authority for boards of nursing to regulate prescription writing by advanced practice nurses e. Nurses' responsibility for delegating to LPN/LVNs
During orientation to a new job, a nurse questions the preceptor about the reason for not milking or stripping a client's chest tube and is told that it is against agency policy
The nurse then realizes that this procedure should not be done because doing so would: 1. anger the new employer. 2. extend the orientation period. 3. expose the nurse to legal liability. 4. make the client less confident in care provided.