A patient with severe abdominal pain rates the pain as 9 out of 10 but has a normal blood pressure and pulse. Which nursing principle should guide the assessment?
Correct answer: B. The patient’s self-report is the primary pain measure
- A. Pain is present only when vital signs change
- B. The patient’s self-report is the primary pain measure
- C. A normal pulse rules out serious pain
- D. The nurse should use facial expression instead of the rating
Explanation
Pain is subjective, and the patient’s self-report is the most reliable measure when the patient can communicate. Vital signs and observed behaviour provide additional information but do not confirm or disprove the severity of 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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