An adolescent hospitalized with sickle cell anaemia reports to the nurse of experiencing a pain level of 10 on a 0 to 10 numerical scale. The nurse observes the adolescent on a phone call laughing. Which action should the nurse take?

Introduce non-pharmacologic strategies for pain reduction.

Allow adequate privacy and time for the client's phone call.

Document the concern of incongruent pain rating and behaviour.

Administer pain medication per the healthcare provider's orders.

Answer and Explanation

The Correct Answer is C

A. While non-pharmacologic strategies are important for pain management, they are typically introduced after initial assessment and understanding of the client's pain experience. In this case, the priority is to clarify the apparent discrepancy between the reported pain level and observed behavior.

B. Respecting the client's privacy and providing time for personal activities like phone calls is important but does not directly address the concern of incongruent pain assessment and behavior.

C. Incongruence between reported pain intensity (10/10) and observed behavior (laughing on the phone) suggests a potential discrepancy that needs to be documented and further investigated. This documentation is crucial for accurate assessment and communication among the healthcare team.

D. Administering pain medication immediately without further assessment may not be appropriate if there is uncertainty about the accuracy of the pain report. It's important to first clarify and validate the client's pain experience before proceeding with medication administration.

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Correct Answer is A

No explanation

A. The client may be experiencing stress at home or at school. B. The client may be taking too much insulin. C. The client may be ingesting too many calories for his energy needs. D. The client may be eating fewer carbohydrates. E. The client may have increased insulin requirements due to puberty.

Correct Answer is ["A","C","D","E"]

No explanation

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An adolescent hospitalized with sickle cell anaemia reports to the nurse of experiencing a pain level of 10 on a 0 to 10 numerical scale. The nurse observes the adolescent on a phone call laughing. Which action should the nurse take?

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