Never assume a calm or sleeping patient has no pain; some patients mask pain or withdraw.
Before you read
Test yourself first: 5 questions
Question 1 of 5
A nurse is using a pain rating scale for an alert adult client. Which scale is most appropriate?
Answer: B. The 0-to-10 numeric rating scale is the standard self-report tool for alert, oriented adults who can quantify pain. Behavioral and faces scales are reserved for clients who cannot self-report numerically.
Question 2 of 5
A nurse is caring for a nonverbal client with advanced dementia who appears to be in pain. Which assessment approach is most appropriate?
Answer: A. When a client cannot self-report, the nurse uses a validated behavioral observation tool such as PAINAD, which scores breathing, vocalization, facial expression, body language, and consolability. Behavioral cues become the primary indicator of pain.
Question 3 of 5
A nurse evaluates the effectiveness of a pain intervention. When should the nurse reassess pain after administering an IV opioid?
Answer: A. IV opioids reach peak effect within roughly 15 to 30 minutes, so the nurse reassesses pain about 15 to 30 minutes after IV administration. Oral analgesics are typically reassessed around 60 minutes. Reassessment confirms effectiveness and guides further action.
Question 4 of 5
A nurse is assessing a client's pain. Which statement reflects the most accurate principle of pain assessment?
Answer: A. Pain is subjective; the single most reliable indicator is the client's self-report. The nurse should accept and act on the client's report rather than judging it against objective signs.
Question 5 of 5
A hospice client has increasing pain near the end of life. The nurse's approach to pain is to:
Answer: B. In hospice/palliative care, the priority is comfort — titrate opioids/analgesics to relieve pain even if it may have side effects (the principle of double effect), and address total comfort. Withholding pain medication out of fear of addiction is inappropriate at end of life.
Keep the streak going with more questions like these, each with a full rationale.
What is pain assessment scales?
Scales standardize that report so pain can be tracked and treated. The right scale depends on the patient's age, development, and ability to communicate. Use the same scale each time for a given patient to trend accurately.
Key points to remember
- The numeric rating scale (0 = no pain, 10 = worst pain) is the standard for alert adults who can self-report.
- Wong-Baker FACES is used for children 3 and older and for adults with language or cognitive barriers.
- FLACC (Face, Legs, Activity, Cry, Consolability) is a behavioral scale for infants and nonverbal patients.
- CRIES and the Neonatal Infant Pain Scale (NIPS) assess pain in neonates.
- PQRST or OLDCARTS frameworks capture a full pain history: provocation, quality, region, severity, and timing.
- Self-report is always the most reliable indicator; behavioral and physiologic signs are used only when self-report is impossible.
Signs & symptoms
- Grimace, guarding, ↑HR/BP
- Restless, withdraw, cry
Nursing priorities
- Choose an age- and ability-appropriate scale and use that same scale at every reassessment.
- Assess pain on admission, at rest and on movement, and reassess after every intervention.
- Reassess after IV analgesia within 15-30 minutes and after oral analgesia within 60 minutes.
- Believe and document the patient's self-reported number without judgment.
- Assess pain as the fifth vital sign alongside the full set of vital signs.
Patient teaching
- Explain that 0 means no pain and 10 means the worst pain imaginable, and ask the patient to pick a number.
- Tell the patient to report pain early rather than waiting until it is severe.
- Encourage the patient to describe pain quality, location, and what makes it better or worse.
Red flags: report now
- Never assume a calm or sleeping patient has no pain; some patients mask pain or withdraw.
- Report new, sudden, or sharply escalating pain, as it may signal a complication, not just undertreatment.
- Do not delay or withhold ordered analgesia because vital signs appear normal despite a high pain score.
References
Clinical references for this topic
