A nurse is assessing a client's pain and notes that the client is grimacing, guarding the affected area, and rating their pain as 8 out of 10. What action should the nurse take?

Answer: a. Acute pain Explanation: The client's symptoms of dilated pupils, increased blood pressure, and increased heart rate are consistent with the physiological responses associated with acute pain. Acute pain is typically a temporary and intense pain response.

b. Chronic pain refers to pain that lasts for an extended period, typically more than three months, and may not be associated with the same physiological responses as acute pain.

c. Visceral pain refers to pain originating from the internal organs, and the symptoms described are not specific to this type of pain.

d. Neuropathic pain is caused by nerve damage or dysfunction, and the symptoms described are not specific to this type of pain.

Answer: c. Provide non-pharmacological pain relief measures.

Explanation: The client's grimacing, guarding, and high pain rating indicate significant pain. The nurse should initiate non-pharmacological pain relief measures, such as positioning, relaxation techniques, heat or cold therapy, or distraction, to help alleviate the pain.

a. Documenting the findings and reassessing the pain in 30 minutes may delay appropriate pain relief measures if the client is experiencing significant pain.

b. Administering the maximum prescribed dose of pain medication should be based on a comprehensive pain assessment and healthcare provider's order.

d. Initiating a consultation with a physical therapist may be appropriate in certain cases, but immediate non-pharmacological pain relief measures should be provided first.