The nurse observes a patient lying rigidly in bed and taking shallow breaths. The patient reports a pain score of 4 out of 5 and says, "My leg hurts." The nurse determines that the objective and subjective data are
a. incongruent and require more assessment.
b. insufficient to make any conclusions.
c. congruent and support that the patient is in pain.
d. unclear; the nurse needs to talk to the patient's family for more information.
ANS: C
A
The statement and behaviors observed indicate that the patient is experiencing pain.
B
One can make a conclusion because there is sufficient information available.
C
The patient states he/she is in pain and the rigid positioning and shallow breathing are behaviors found when individuals experience pain.
D
The subjective nature of pain requires obtaining the information from the patient if at all possible. The family can be an excellent source of information if the patient is unable to cooperate with the nurse's assessment.
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