When following up on a client's report of hip pain during an admission assessment, the most nursing conclusive observation would be:
1. The client tearing when being ambulated to the chair
2. A report from the ancillary staff that the client is reporting pain
3. The client observed grimacing when positioning self in the bed
4. Overhearing the client discuss hip pain with family on the phone
ANS: 3
This option where the client was observed grimacing describes nonverbal actions that are associ-ated with pain when the client is unaware of being observed and so represents the most conclu-sive follow-up evidence of pain. The options where the client is tearing when ambulated to the chair, the ancillary staff's report of the client's pain as well as overhearing the client discuss hip pain may well be an observation of pain, but they are not the most conclusive of the options be-cause the client is aware of being observed.
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