Answer to Question 1
Ans: D
The client's subjective self-report of pain is the priority assessment finding and reflects the adage that pain is what the client says it is. The nurse should not discount the reports of clients based on medical diagnoses and expected findings, because the client has a history of cognitive deficits, or because the client does not appear to be in pain.
Answer to Question 2
Ans: D
Essential assessment information is also obtained by observing for nonverbal indicators of pain, such as grimacing, muscle tension, rubbing, and protecting body parts. Relying on vital signs, presuming that sleeping clients are not experiencing pain, and relying on the absence of reporting of pain are all flawed pain assessment techniques.
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