NCLEX RN Practice Question

The correct answer involves further assessment of the client's pain level using appropriate tools for a non-verbal client. Non-verbal cues such as restlessness, avoiding eye contact, and tightly gripping the bedrails often indicate distress, possibly due to uncontrolled pain. Addressing potential pain as a primary stressor is critical before assuming other causes like anxiety or environmental factors. While adjusting the environment and providing reassurance may be helpful, these actions should follow pain assessment and management to ensure the client’s immediate comfort. Simply observing without intervention delays care.