A seven-year-old has just returned to the unit from the operating room after undergoing an appendectomy. When asked, the child states that his pain is a 1 on a scale of 0 to 10. Which finding makes the nurse question this response?
1. Lies rigid in bed, refusing to move
2. Eyes closed, flat effect
3. Turning away from the nurse, avoiding eye contact
4. Mother states that the child is in pain.
1
Rationale 1: Body language tells the nurse that he is in severe pain.
Rationale 2: The face does not display symptoms of pain. Painful expression on the face would include grimaces and lowered brows. Tears may or may not be present.
Rationale 3: This expression could indicate shyness, not pain.
Rationale 4: Although the mother knows her child, she is also anticipating the child is in pain. The child's body language is a better indicator of pain.
Global Rationale:
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