A patient verbalizes a low pain level of 2 out of 10 but exhibits extreme facial grimacing while moving around in bed. What is the nurse's initial action in response to these observations?

A) Proceed to the next patient's room to make rounds.
B) Determine the patient does not want any pain medicine.
C) Ask the patient about the facial grimacing with movement.
D) Administer the pain medication ordered for moderate to severe pain.

Question

Blake Cooper · Accepted Answer

Final Answer : C, Explanation :  First, the nurse needs to clarify/verify what was observed with what the patient states. Proceeding to the next room is ignoring this visual cue. The nurse cannot assume the patient does not want pain medicine just because he reports a 2 out of 10 on the pain scale. The nurse should not administer medication for moderate to severe pain if it is not necessary.

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