The nurse is caring for a client.

Which of the following actions should the nurse take? Select all that apply.

Rationale:
A. The nurse should not administer another dose of ibuprofen without first completing a proper pain assessment and verifying that it is safe based on dosing intervals and provider orders. Ibuprofen dosing is typically scheduled at specific intervals, and giving an additional dose without assessment may lead to overdose or adverse effects such as gastrointestinal bleeding or renal impairment.

B. The first action should always be to reassess the client’s pain using a standardized pain scale. Pain is subjective, and the nurse must gather objective data about severity, quality, and response to previous interventions before determining the next step. This assessment guides appropriate and safe intervention.

C. While the provider may need to be notified if pain is uncontrolled, the nurse must first assess the pain level and characteristics. Without reassessment, the nurse does not have sufficient data to communicate effectively or advocate for changes in the treatment plan.

D. Escalation to opioid therapy may be appropriate if pain is severe and unrelieved, but this decision must be based on a full assessment. Jumping directly to requesting opioids without reassessing violates the nursing process and may lead to inappropriate prescribing.

Rationale:

A. Although this statement may be true, it is a form of reassurance that can dismiss the client’s expressed feelings. It does not address the emotional distress the client is communicating and may discourage further sharing.

B. This response uses therapeutic communication by reflecting feelings and acknowledging the client’s emotional experience. After a cerebrovascular accident (CVA), clients often experience frustration due to loss of independence and prolonged rehabilitation. Validating emotions encourages trust and further communication.

C. This is giving advice and shifting responsibility away from the nurse-client therapeutic relationship. While social support is important, the nurse should first explore and acknowledge the client’s feelings.

D. This deflects the client’s concern and avoids therapeutic communication. The nurse should first address emotional expression directly before involving other members of the health care team.