The nurse is assessing a client who has had a cerebral vascular accident (CVA or stroke) and has difficulty with verbal expression, but no other deficits. What approach should the nurse use to assess this client's level of pain?
1. The nurse asks the client's family member to place a number on the client's pain using a scale of 0 (no pain) to 10 (most pain), since the family member knows the client best.
2. The nurse considers the client's behavior and vital signs and determines a number from the pain scale (0–10) based on these objective findings.
3. The nurse uses the Wong-Baker "FACES" pain rating scale.
4. The nurse reviews the previous pain assessments and makes a determination based on these findings.
3
Rationale 1: The family member is not able to accurately identify the client's pain level because pain is entirely subjective and personal.
Rationale 2: The nurse incorporates objective findings into a thorough pain assessment, but pain is ultimately what the client says it is.
Rationale 3: Pain is an entirely subjective and personal experience. Because this client has difficulty with verbal expression, but no other deficits, the nurse could use the "FACES" pain scale and ask the client to point to the picture that most closely correlates with current level of pain.
Rationale 4: Previous assessments can help the nurse to determine a pattern of the client' pain and pain control, but does not give the nurse any clues about the client's current pain.
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