The nurse is caring for a client in palliative care who is alert and oriented to person, place, and time. Which assessment data would be most appropriate in determining the client's need for pain medication?
A) Ask the client to rate his pain.
B) Observe the client's face for signs of pain.
C) Evaluate the client's heart rate, blood pressure, and pulse rate.
D) Ask the client's spouse if the client is in pain.
A) Ask the client to rate his pain.
Explanation: A) Comprehensive pain assessment is essential, with particular attention given to the patient's self-report of pain, including location, intensity, quality, pattern, and effects on function. Because this client is alert and oriented, the client's self-report of pain should be used to determine whether the client is in pain.
B) Comprehensive pain assessment is essential, with particular attention given to the patient's self-report of pain, including location, intensity, quality, pattern, and effects on function. Because this client is alert and oriented, the client's self-report of pain should be used to determine whether the client is in pain.
C) Comprehensive pain assessment is essential, with particular attention given to the patient's self-report of pain, including location, intensity, quality, pattern, and effects on function. Because this client is alert and oriented, the client's self-report of pain should be used to determine whether the client is in pain.
D) Comprehensive pain assessment is essential, with particular attention given to the patient's self-report of pain, including location, intensity, quality, pattern, and effects on function. Because this client is alert and oriented, the client's self-report of pain should be used to determine whether the client is in pain.
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