The nurse is assessing a client who is recovering from open-heart surgery. Which assessment data is most reflective of a client's pain response?
1. Family report of pain.
2. Response from the client based on use of a pain tool.
3. Observations of the client's behaviors while asleep.
4. Measurement of vital signs.
Correct Answer: 2
The use of a standardized pain tool that has been discussed with the client preoperatively will provide the most useful data. The family may perceive the client to be in pain when she is not. Observations of behavior while the client is asleep may indicate pain, but use of a tool while the client is awake would be more accurate. Vital sign changes may be a result of the body's response to surgery and not just specifically to pain.
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