A nurse is caring for a patient receiving IV therapy in the left forearm and notices that the site is red, swollen, and warm.
What action should the nurse take first?

The correct answer is choiceD.

Choice A rationale:

Assisting the client back into bed is not the initial action.Moving the client without assessing their condition could potentially cause harm.

Choice B rationale:

Notifying the client’s provider is important, but it should be done after assessing the client’s condition to provide accurate information.

Choice C rationale:

Informing the client’s family member is not the immediate priority.The nurse should first ensure the client’s safety and assess their condition.

Choice D rationale:

Obtaining the client’s vital signs is the initial action.This helps assess the client’s current condition and determine if there are any immediate medical needs.

Choice A rationale:

Chronic pain can manifest in various behavioral and physical symptoms, including restlessness, pacing, grimacing, and other facial expressions of pain. These behaviors are often unconscious attempts to cope with or distract from the pain.

They may also reflect the emotional distress that often accompanies chronic pain. Patients may feel frustrated, anxious, or even depressed due to the persistent nature of their pain and its impact on their lives.

It's crucial for nurses to recognize these behavioral signs of pain, as patients may not always readily report their pain verbally. By observing these behaviors, nurses can assess the patient's pain level more accurately and provide appropriate interventions.

Choice B rationale:

Chronic pain is defined as pain that persists for longer than three months, often for much longer. It is not limited and short in duration.

This distinguishes it from acute pain, which is typically associated with an injury or illness and resolves within a few days or weeks.

Choice C rationale:

While some patients with chronic pain may have physical signs of tissue injury, this is not always the case. Chronic pain can also be caused by nerve damage, inflammation, or changes in the central nervous system.

In some cases, the underlying cause of chronic pain may be unknown.

Choice D rationale:

Although chronic pain may not always cause a significant change in vital signs, it can still be a very real and debilitating experience for patients.

Vital signs, such as heart rate, blood pressure, and respiratory rate, are often more sensitive to acute pain.

Nurses should not rely solely on vital signs to assess chronic pain. Instead, they should consider the patient's self-report of pain, behavioral cues, and other factors.