Fundamentals of Nursing Q 500
For a cognitively impaired client who cannot accurately report pain, what is the first action that you should take?
A. Closely assess for nonverbal signs such as grimacing or rocking.
B. Obtain baseline behavioral indicators from family members.
C. Look at the MAR and chart, to note the time of the last dose and response.
D. Give the maximum PRS dose within the minimum time frame for relief.
Correct Answer: B. Obtain baseline behavioral indicators from family members.
Complete information from the family should be obtained during the initial comprehensive history and assessment. If this information is not obtained, the nursing staff will have to rely on observation of nonverbal behavior and careful documentation to determine pain and relief patterns.
Option A: Pain can be difficult to assess in cognitively impaired individuals because their self-reports of pain can be inaccurate or difficult to obtain. Thus, behavioral observation-based assessment is optimal in these patients.
Option C: Assess potential causes of pain. The clinician should consider pathological causes of pain and any procedure known to cause pain. Address any pain history from family, significant others, and caregivers.
Option D: Use scheduled dosing when pain is chronic and/or when the patient is unable to ask for medication. When administering the medication, it is best to start with a lower dose and gradually increase the dose to alleviate the pain.