A client is observed holding a pillow over the abdominal region with both knees flexed in a side-lying position. Vital signs assessment reveals an elevated blood pressure and heart rate. Which of the following should the nurse say to this client?
1. "Can I get you anything?"
2. "Would you like something for pain?"
3. "You look comfortable."
4. "Your blood pressure is up."
2
Sympathetic responses to pain include elevated blood pressure and heart rate. And since the client is hugging a pillow over the abdominal region with both knees flexed in a side-lying position, the best thing for the nurse to say to this client is "Would you like something for pain?" The other responses are incorrect because they do not acknowledge that the client is experiencing pain.
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