The client rings the nurse call button and requests pain medication. Upon assessment, the nurse finds the client sitting up in a chair, watching television with a friend. Vital signs are normal and the client's skin is warm and dry
Which nursing actions are appropriate?
Standard Text: Select all that apply.
1. Ask the client to rate his pain on the pain scale.
2. Tell the client that he does not look as if he is in pain.
3. Have the client go back to bed and ask the visitor to leave.
4. Check to see when the client last received pain medication.
5. Have another nurse assess the client.
Correct Answer: 1,4
Rationale 1: When the client complains of pain, the nurse should always ask for a pain rating.
Rationale 2: Clients respond to pain differently. For example, this client may be trying to hide the intensity of his pain from his friend.
Rationale 3: Having the client go back to bed and asking the visitor to leave is punitive and could be interpreted as the nurse not believing the client. Being active and having diversions can help with pain management.
Rationale 4: The nurse should check to see when the client last had pain medication, what drug was given, what dose was given, and by what route it was administered.
Rationale 5: There is no reason to have another nurse assess the client. This action may imply that the nurse does not trust the client.
Global Rationale: When the client complains of pain, the nurse should always ask for a pain rating. The nurse should check to see when the client last had pain medication, what drug was given, what dose was given, and by what route it was administered. Clients respond to pain differently. For example, this client may be trying to hide the intensity of his pain from his friend. Having the client go back to bed and asking the visitor to leave is punitive and could be interpreted as the nurse not believing the client. Being active and having diversions can help with pain management. There is no reason to have another nurse assess the client. This action may imply that the nurse does not trust the client.
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