Can someone explain the rationale for this?

[DBK99]

When going over the questions a few days after the test, I forgot to read what the rationale was:

Patient is complaining of hip pain. Which event would best validate the patient's complaints to the nurse?

A. Overhearing patient discuss hip pain with family member on phone

B. Patient grimacing when positioning self in bed

C. Patient tearing when being ambulated to wheelchair

D. Ancillary staff tells nurse "patient reports increasing hip pain"

I chose the right answer, which was B. But I couldn't tell you why I chose it, it just stood out to me & was my first instinct. But I'd like to know WHY it's the right answer. If anyone has some insight, I'd appreciate it :)

[lovescoffee]

When going over the questions a few days after the test, I forgot to read what the rationale was:

Patient is complaining of hip pain. Which event would best validate the patient's complaints to the nurse?

A. Overhearing patient discuss hip pain with family member on phone

B. Patient grimacing when positioning self in bed

C. Patient tearing when being ambulated to wheelchair

D. Ancillary staff tells nurse "patient reports increasing hip pain"

I chose the right answer, which was B. But I couldn't tell you why I chose it, it just stood out to me & was my first instinct. But I'd like to know WHY it's the right answer. If anyone has some insight, I'd appreciate it :)

In my opinion, "B" is correct because it decreases the likelihood that the patient is "performing" (for lack of a better term). Many times patients friends/family cause the patient to be more dramatic or instigate any problem (pain, ect) the patient may be having. Though pain self reports (the #/10 pain scale) are suppose to always be what we use to gauge, I've seen many patients chatting and laughing on the phone while reporting 10/10 pain. As for option "C", if a patient in the hospital is ambulating to a wheelchair there should be a tech/RN present which causes this to fall under the above.

Hope this helps!

[llg, PhD, RN]

Because A, C, and D could be lies. The patient could be exaggerating her pain to her family on the phone ... or tearing up about something else ... and the patient could be lying/exaggerating to the ancillary staff.

Technically, her grimace could be "an act," but it's less likely to be. It's most likely a spontaneous response to pain. A spontaneous grimace is a visible sign of pain that can be faked, but is probably not fake. But because it can be faked, it's only a slightly better answer to the question.

[Jayden8139]

Too piggyback on that. B is the best answer because it's objective data. The most reliable. The others are subjective.

[milksteak]

Yep, like Jayden said, it's because its objective data that was witnessed by the nurse herself.

[DBK99]

Thanks for all your replies! I think I get it..This may be a dumb question, but would patient tearing when being ambulated to wheelchair not be "objective data that was witnessed by the nurse herself" also, if witnessing the patient grimacing is objective? Couldn't the grimace and the tears both be faked? Or the grimace and tears be about something completely different than hip pain?

[nurseprnRN, BSN, RN]

the nclex always wants to know what you, the nurse, observes and concludes from it. so someone else's reports are not as valid for the purpose of the nursing process as your own observation/assessment. that's why b is best.