59. Client assessment for pain should include a general history, clinical examination, and a pain history. A nurse knows that the most reliable indication of pain severity is:
59. Client assessment for pain should include a general history, clinical examination, and a pain history. A nurse knows that the most reliable indication of pain severity is:
. Responsiveness to ordered drugs.
. Client's self-report.
. Duration of the pain.
. Presence of facial grimaces.
Test-Taking Tip
The question asks for the most reliable indication—what the client says!
Content Area: Adult Health, Pain Control; Integrated Process: Nursing Process, Analysis; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Vital Signs Changes/Abnormalities
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Answer 1 is incorrect because the effectiveness of drugs varies from client to client. Answer 2 is correct because pain is what the client reports it to be: severe, unrelenting, or relieved. Pain is now considered as the fifth vital sign. Answer 3 is incorrect because duration (how long the pain has persisted) is not an indication of severity, which can be mild, moderate, severe, or excruciating. Answer 4 is incorrect because cultural norms may alter expressions of pain. The stereotypical "stoic Asian" may not show an expression recognized by others as pain.