Difficulty: Medium
Average Score: 65%
Simulated
The nurse is caring for a client who is sedated and on the ventilator in ICU. The family expresses concern about controlling the client's pain when he cannot speak. The nurse explains that assessing pain in a nonverbal client involves watching for which of the following signs? Select all that apply.
Correct answer
B,C,D,F
Rationale
Biting tubing (B), grimacing (C), stiffness/rigidity (D), and elevated BP/heart rate (F) indicate pain in nonverbal clients. Grabbing rails (A) is less specific, and urinary output (E) is unrelated.