A nurse performs an assessment of pain discrimination on an older adult client. The client correctly identifies, with eyes closed, a sharp sensation on the right hand when touched with a pin. Which action should the nurse take next?
a. Touch the pin on the same area of the left hand.
b. Contact the provider with the assessment results.
c. Ask the client about current medications.
d. Continue the assessment on the client's feet.
ANS: A
If testing is begun on the right hand and the client correctly identifies the pain stimulus, the nurse should continue the assessment on the left hand. This is a normal finding and does not need to be reported to the provider, but instead documented in the client's chart. Medications do not need to be assessed in response to this finding. The nurse should assess the left hand prior to assessing the feet.
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