The nurse is caring for a client receiving mechanical ventilation.
Which client finding would require the nurse to perform a pain assessment?
The nurse is caring for a client receiving mechanical ventilation.
Which client finding would require the nurse to perform a pain assessment?
A. Lower blood pressure when compared to baseline
[9%]
B. Relaxed facial expression
[10%]
C. Frequent sounding of the high-pressure alarm
[65%]
D. No movement of the upper limbs
[16%]
Statistics
Subject/Lesson
Subject
Critical Care
Lesson
Critical Care Concepts
Client Need
Test Plan
Pharmacological and Parenteral Therapies
Related Topic
Pharmacological Pain Management
Item Type
Item Type
Analysis
Explanation
Choice C is correct. When a client receives mechanical ventilation, they should be assessed for pain. Pain assessment tools like the critical care pain observation tool (CPOT) may determine a client's pain via nonverbal cues. One of the aspects of the assessment is the client's compliance with the ventilator. The client biting the tube or breathing over the ventilator will trigger the high-pressure alarm, which should prompt the nurse to assess the client if they need to be suctioned or if they are in pain.
Choice A is incorrect. A decrease in blood pressure is not a typical sign of pain in a mechanically ventilated client. Pain more commonly leads to increased blood pressure and heart rate due to sympathetic nervous system activation.
Choice B is incorrect. A client who displays a relaxed facial expression is unlikely to be in distress or pain. This observation suggests that the client is comfortable, making a pain assessment unnecessary at that moment.
Choice D is incorrect. Lack of limb movement may be related to sedation, neuromuscular blockade, or neurological impairment. It does not directly indicate that the client is in pain and, therefore, would not trigger the need for a pain assessment.
Related Videos
2 Key Topics
Ventilators- Critical Care
27.1 Critical Care Respiratory System
Additional Info
✓ All clients should be assessed for pain
✓ The nurse should appreciate pain assessment challenges such as clients cognitively impaired, critically ill (intubated, unresponsive), unconscious, or imminently dying
✓ Accepting the client's self-report is the gold standard for an appropriate pain assessment
✓ For those receiving mechanical ventilation, the client should be assessed for non-verbal cues such as increased blood pressure, pulse, facial grimacing, non-compliance with the ventilator, and a tense posture
