The nurse is interviewing a client who is in acute pain. Which of the following actions by the nurse must be performed first?
1. Interview the family for the information.
2. Attempt to reduce the pain and complete the interview later.
3. Proceed very quickly with the interview.
4. Document why the interview could not be completed.
2
Rationale 1: Although secondary sources (family members, the medical record, and other members of the healthcare team) can be used to gather data, the client provides the primary information and should be the first choice for data assessment when possible.
Rationale 2: The ability to participate in an interview is diminished when the client is experiencing unrelieved or acute pain. The nurse must focus on measures to help relieve pain, and then gather in-depth information at another time.
Rationale 3: The client will not be able to concentrate and provide as in-depth information as possible if experiencing pain; regardless of how fast or slow the process takes.
Rationale 4: Pain reduction is the primary goal in this situation, as the interview must be completed in order to obtain necessary data.
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