Which of the following assessment data will be most reflective of a client's pain response following open-heart surgery?
1. Family report of pain
2. Response from the client based on use of a pain tool
3. Observations of the client's behaviors while asleep
4. Measurement of vital signs
2
Rationale 1: The family may perceive the client to be in pain when she is not.
Rationale 2: The use of a standardized pain tool that has been discussed with the client preoperatively will provide the most useful data.
Rationale 3: Observations of behavior while the client is asleep may indicate pain, but use of a tool while the client is awake would be more accurate.
Rationale 4: Vital sign changes may be a result of the body's response to surgery and not just specifically to pain.
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