A confused patient is admitted to the hospital after suffering a fall. When asked about pain, the patient does not respond. What action by the nurse is best?
a. Ask the patient again using different words.
b. Pantomime what you are asking the pa-tient.
c. Observe the patient's nonverbal behaviors.
d. Ask the family members if they think the patient has pain.
C
In some situations, the nurse cannot rely on the patient's report of pain, so as a second method of assessment, the nurse looks to the patient's nonverbal behaviors. The nurse should be aware, however, that the lack of specific "pain behaviors" does not indicate a lack of pain. The other options may be helpful for individual patients.
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a. 0800 b. 1200 c. 1600 d. 2100