An oriented patient has recently had surgery. Which action is best for the nurse to take to assess this patient’s pain?
a. Assess the patient’s body language.
b. Ask the patient to rate the level of pain.
c. Observe the cardiac monitor for increased heart rate.
d. Have the patient describ...
HESI RN COMPREHENSIVE PREDICTOR EXAM
An oriented patient has recently had surgery. Which action is best for the
nurse to take to assess this patient’s pain?
a. Assess the patient’s body language.
b. Ask the patient to rate the level of pain.
c. Observe the cardiac monitor for increased heart rate.
d. Have the patient describe the effect of pain on the ability to cope.
ANS: B
One of the most subjective and therefore most useful characteristics for
reporting pain is its severity. Therefore, the best way to assess a patient’s pain
is to ask the patient to rate the pain. Nonverbal communication, such as body
language, is not as effective in assessing pain, especially when the patient is
oriented. Heart rate sometimes increases when a patient is in pain, but this is
not a symptom that is specific to pain. Pain sometimes affects a patient’s
ability to cope, but assessing the effect of pain on coping assesses the
patient’s ability to cope; it does not assess the patient’s pain.
2.A nurse is caring for a patient who recently had abdominal surgery and is
experiencing severe pain. The patient’s blood pressure is 110/60 mm Hg,
and heart rate is 60 beats/min. Additionally, the patient does not appear to
be in any distress. Which response by the nurse is most therapeutic?
“Your vitals do not show that you are having pain; can you describe
a. your pain?”
b. “OK, I will go get you some narcotic pain relievers immediately.”
c. “What would you like to try to alleviate your pain?”
d. “You do not look like you are in pain.”
ANS: C
Be sure the patient is a partner in making decisions about the best approaches
for managing pain. A patient knows the most about his or her pain and is an 205
important partner in selecting successful pain therapies. The nurse must
believe that a patient is in pain whenever the patient reports that he or she is
in
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