The practical nurse (PN) is performing a pain assessment on a client. Which factor(s) have been shown to have an effect on a client's perception of pain and will most likely increase the perception of pain? Select all that apply.

Rationale:

A. Normal should be within 3 seconds or 5 seconds in the older adult: While refill times can slow slightly with age, the standard clinical benchmark for a "normal" capillary refill is less than 2 seconds. In a fresh fracture and cast, a 4-second refill is a critical finding suggesting impaired peripheral perfusion

B. Use your thumbnail and press the nailbed proximal to the injury: Applying pressure with the thumbnail can cause unnecessary discomfort or injury, especially near a fractured limb. The standard technique is to press directly on the nailbed with a fingertip to avoid trauma while still effectively assessing perfusion.

C. Capillary refill is measured in seconds: Measuring the refill in seconds allows the nurse to quantify the perfusion and detect early signs of compromised circulation, which is critical for timely intervention in a client with a new cast and risk of neurovascular compromise.

D. Pressure placed on the nailbed should cause blanching: Blanching occurs when blood is temporarily displaced from the capillaries. Observing this response ensures that the capillary refill can be accurately timed, providing an objective assessment of blood flow distal to the fracture site.

E. Capillary refill is the time it takes to return to the client's normal color after releasing pressure: This step is the essence of the capillary refill test. It reflects the speed of arterial blood return, which is a vital indicator of adequate peripheral perfusion and early detection of circulatory compromise under a cast.

Rationale:

A. Instruct the client to close both eyes, then repeat the assessment: Closing the eyes is not necessary for pupillary assessment and does not provide additional diagnostic information. Pupillary response should be assessed in an open-eye, properly illuminated environment to observe the direct light reflex accurately.

B. Notify the charge nurse of the assessment finding immediately: A brisk pupillary constriction is a normal direct light reflex and does not indicate an emergent or abnormal finding. Immediate reporting is not required unless the response is abnormal, sluggish, or absent, which could suggest neurological impairment.

C. Shine the light over the other pupil and observe the response: After assessing one eye, the nurse should evaluate the contralateral eye to observe both the direct and consensual light reflexes. This ensures both eyes are functioning appropriately and can reveal potential asymmetry in neurological function or optic nerve integrity.

D. Hold the light over the pupil until it dilates back to the original size: Pupils naturally constrict and then slowly re-dilate after light removal. Prolonged exposure does not provide further clinical insight and may cause discomfort. The assessment should focus on speed, symmetry, and completeness of constriction and consensual response rather than continuous illumination.