A patient reports pain as 6 out of 10 but is smiling and talking with visitors. Which nursing action is most appropriate?
Correct answer: B. Use the patient’s self-report as the primary pain measure
- A. Accept the facial expression as proof of mild pain
- B. Use the patient’s self-report as the primary pain measure
- C. Delay assessment until the patient shows guarding
- D. Record the pain as zero because vital signs are normal
Explanation
Pain is subjective, and the patient’s self-report is the most reliable indicator when the patient can communicate. Smiling, talking, or normal vital signs do not rule out significant pain.
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About Vital Signs and Monitoring
Vital signs include temperature, pulse, respiration, blood pressure, oxygen saturation and pain assessment. Coverage includes correct measurement sites and techniques, normal adult ranges, factors that alter readings, trends in patient observations, and the difference between an abnormal finding that needs reassessment and one requiring immediate reporting.
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