An older client with a speech deficit from a previous stroke is admitted for a repair of a hip fracture. Which techniques will the nurse use to assess this client's pain level? Select all that apply.
1. Ask to describe the level of pain.
2. Observe for tense body posturing.
3. Listen for sounds such as groaning.
4. Notice changes in appetite or sleep.
5. Observe facial expressions such as grimacing.
2. Observe for tense body posturing.
3. Listen for sounds such as groaning.
4. Notice changes in appetite or sleep.
5. Observe facial expressions such as grimacing.
Explanation: 1. The client is unable to speak, so verbally asking the client to describe the level of pain will not provide the nurse with any information about the client's current level of pain.
2. Tense body posturing is a pain behavior that the client who is unable to speak might demonstrate.
3. Sounds such as groaning are pain behaviors that the client who is unable to speak might demonstrate.
4. Changes in appetite or sleep are pain behaviors that the client who is unable to speak might demonstrate.
5. Grimacing is a pain behavior that the client who is unable to speak might demonstrate.
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