A nurse assesses an older adult client with confusion related to hyponatremia who reports pain. Which of the following data should the nurse use as a guide for choosing interventions?
A) Symptoms of hyponatremia do not include pain.
B) The client does not manifest any outward signs of pain.
C) The client is confused from the pain.
D) The client rates the pain at 8 out of 10.
Ans: D
The client's subjective self-report of pain is the priority assessment finding and reflects the adage that pain is what the client says it is. The nurse should not discount the reports of clients based on medical diagnoses and expected findings, because the client has a history of cognitive deficits, or because the client does not appear to be in pain.
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