Pierro was noted to be displaying facial grimaces after nurse Kara assessed his complaints of pain rated as 8 on a scale of 1 (no pain) 10 10 (worst pain). Which intervention should the nurse do?
A. Administering the client's ordered pain medication immediately.
B. Using guided imagery instead of administering pain medication.
C. Using therapeutic conversation to try to discourage pain medication.
D. Attempting to rule out complications before administering pain medication.
Correct Answer: D. Attempting to rule out complications before administering pain medication.
When intervening with a client complaining of pain, the nurse must always determine if the pain is expected pain or a complication that requires immediate nursing intervention. This must be done before administering the medication. Perform a comprehensive assessment of pain. Determine via assessment the location, characteristics, onset, duration, frequency, quality, and severity of pain.
Option A: Perform a history assessment of pain. Additionally, the nurse should ask the following questions during pain assessment to determine its history: (1) effectiveness of previous pain treatment or management; (2) what medications were taken and when; (3) other medications being taken; (4) allergies or known side effects to medications.
Option B: Guided imagery should be used along with, not instead of, administration of pain medication. Guided imagery involves the use of mental pictures or guiding the patient to imagine an event to distract from the pain.
Option C: The nurse should medicate the client and not discourage medication. Nurses have the duty to ask their clients about their pain and believe their reports of pain. Challenging or undermining their pain reports results in an unhealthy therapeutic relationship that may hinder pain management and deteriorate rapport.
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