The nurse observes an older patient crying, tensed, and lying rigidly in bed. What action should the nurse take first?
A) Reposition the patient in bed
B) Perform a systematic pain assessment
C) Ask the patient if she is experiencing a problem
D) Prepare a dose of breakthrough medication for the patient.
C
Feedback:
Part of comforting is the perception of patients' problems. The nurse should ask the patient to describe any problems she is currently experiencing. It would be premature to draw up breakthrough analgesia or to reposition the patient before further assessment, while a pain assessment may be inappropriate given the multiple potential causes of the patient's affect.
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a. Assessment b. Analysis c. Planning d. Implementation e. Evaluation