The nurse is caring for a client with acute bone pain related to metastases of cancer. The best way for a hospice nurse to assess the client's level of pain is:
The nurse is caring for a client with acute bone pain related to metastases of cancer. The best way for a hospice nurse to assess the client's level of pain is:
A. Check vital signs after giving pain medication.
[3%]
B. Note observations about the client's behavior.
[4%]
C. Evaluate verbal and non-verbal actions.
[17%]
D. Ask the client to rate their pain on a scale from 0-10.
[75%]
Statistics
Subject/Lesson
Subject
Adult Health
Lesson
Hematological/Oncological
Client Need
Test Plan
Basic Care and Comfort
Related Topic
Non-Pharmacological Comfort Interventions
Item Type
Item Type
Application
Explanation
Choice D is correct. Only the client can report their level of pain; it is a subjective perception that should not be judged or dismissed. Asking them to rate their pain on a scale of 0-10 should be the guide for managing care and pain relief. Three aspects of the definitions of pain have essential implications for nurses. First, pain is a physical and emotional experience, not all in the body or all in the mind. Second, it is in response to actual or potential tissue damage, so laboratory or radiographic reports may not be abnormal despite the real pain. Finally, anxiety is described in terms of such loss (e.g. neuropathic pain). Given that some clients are reluctant to disclose the presence of pain unless asked, nurses will be unaware of a client’s pain until they assess for it. Additionally, it is clear that even clients who are nonverbal (e.g. preverbal children, intubated clients, people with cognitive impairments, or those who are unconscious) experience pain that demands nursing assessment and treatment even though the clients are unable to describe their discomfort. Pain interferes with functional abilities and quality of life. Severe or persistent pain affects all body systems, causing potentially dangerous health problems while increasing the risk of complications, delays in healing, and an accelerated progression of fatal illnesses.
Choice A is incorrect. Although vital signs should be measured and may indicate an increased or decreased level of pain, it is not the most accurate way to assess the client’s level of pain.
Choice B is incorrect. Observation of the client's behavior can provide useful insight however, it is not the gold standard for pain assessment.
Choice C is incorrect. Verbal and nonverbal cues from the client can be noted but are also not the best way to gauge a person’s level of pain.
Additional Info
✓ Nurses should use a standardized pain assessment tool, such as the Numeric Rating Scale (0-10), to gauge the intensity of the client's pain. This assessment should be performed regularly to monitor changes and the effectiveness of interventions.
✓ Acknowledge and validate the client's report of pain. Since pain is subjective, the client's description and rating of pain should guide the management plan.
✓ Studies indicate that approximately 20% of adults globally suffer from pain, with chronic pain affecting around 10% of the world's population.
✓ Other pain scales to be familiar with include:
- FLACC Scale (Face, Legs, Activity, Cry, Consolability)
- PAINAD Scale (Pain Assessment in Advanced Dementia)
- BPS (Behavioral Pain Scale)
- CPOT (Critical-Care Pain Observation Tool)
- NVPS (Non-Verbal Pain Scale)
