What steps should a nurse take when a patient reports pain that seems disproportionate to exam findings?

• A. Deny the patient’s pain and ignore.
• B. Immediately administer maximum dose without assessment.
• C. Document pain but take no action.
• D. Acknowledge the pain, reassess using a pain scale, review medications and vitals, consider noninvasive reassessment, and follow orders or escalate for evaluation.

Answer: (D)

When a patient reports pain that seems out of proportion to what is seen on the exam, the priority is to take the patient’s report seriously and respond with a careful, systematic reassessment. Begin by acknowledging the pain and validating the patient’s experience, because pain is subjective and must be addressed even if findings are reassuring. Reassess using a standardized pain scale to quantify the current intensity and to understand the characteristics of the pain (location, quality, onset, duration, aggravating or relieving factors). Review the patient’s current analgesic plan—what was given, when, and at what dose—as well as any allergies or prior responses to pain meds, and check recent vitals to look for trends or potential safety concerns. Consider noninvasive reassessment factors, such as the patient’s cognitive state, anxiety, and need for comfort measures, and apply nonpharmacologic strategies if appropriate. Then follow the standing orders, administer or adjust treatment as indicated, and continue to monitor and reassess promptly to determine the effectiveness of the intervention; escalate for evaluation or adjust the plan with the provider if pain remains uncontrolled or if there are concerning changes in status. This approach protects patient safety, respects their experience of pain, and ensures timely, appropriate management.

Denying, or delaying action without reassessment, or acting without evaluating the pain first, would fail to address the patient’s needs and could allow unnecessary suffering or deterioration.