The nurse enters the postoperative client's room and finds the client perspiring with fists clenched. As the nurse administers routine medications and provides care, the client is pleasant and cooperative. Which action by the nurse is the most appropriate?

Question

1. Documenting "no complaints of pain offered" and assessing that the client is comfortable
2. Asking the client if pain is being experienced
3. Informing the client that he looks uncomfortable and asking him to describe his pain
4. Instructing the client to use the call bell if he experiences pain

Answer 1

3
Rationale 1: The client's body language indicates the likelihood of pain.
Rationale 2: Some clients might feel that admitting to pain is a sign of weakness, and might not bring it up unless the nurse specifically refers to the client's apparent discomfort and asks him to describe his pain and indicates the client's apparent discomfort.
Rationale 3: It is the nurse's responsibility to assess for pain and not wait for the client to mention it.
Rationale 4: Instructing the client to use the call bell puts the responsibility for pain assessment on the client instead of on the nurse.
Global Rationale: It is the nurse's responsibility to assess for pain and not wait for the client to mention it. Some clients might feel that admitting to pain is a sign of weakness, and might not bring it up unless the nurse specifically refers to the client's apparent discomfort and asks him to describe his pain and indicates the client's apparent discomfort. The client's body language indicates the likelihood of pain. Instructing the client to use the call bell puts the responsibility for pain assessment on the client instead of on the nurse.