Question

The nurse is planning care for a client experiencing acute pain. What will the nurse include in the health history portion of the nursing assessment?

1) Using a developmentally appropriate tool
2) Inspecting injuries
3) Monitoring vital signs
4) Assessing facial expressions

Answer 1

When planning care for a client experiencing acute pain, the nurse will include using a developmentally appropriate pain assessment tool, inspecting injuries, monitoring vital signs, and assessing facial expressions in the health history portion of the nursing assessment.

Step-by-step explanation:

When planning care for a client experiencing acute pain, the nurse will include several elements in the health history portion of the nursing assessment. These include:

1. Using a developmentally appropriate tool: The nurse will use a pain assessment tool that is suitable for the client's age and understanding. For example, the nurse may use the Wong-Baker Faces Scale for children or the Numerical Rating Scale for adults.
2. Inspecting injuries: The nurse will visually examine the client's body for any signs of injury or trauma that may be causing the acute pain.
3. Monitoring vital signs: The nurse will regularly check the client's vital signs, such as blood pressure, heart rate, and respiratory rate, to assess any physiological changes associated with the pain.
4. Assessing facial expressions: The nurse will observe the client's facial expressions as they can provide valuable cues about the intensity and location of the pain.