A nurse is assessing a client recovering from surgery who is non-verbal but appears restless. The client is avoiding eye contact, gripping the bed rails tightly, and has a furrowed brow. Based on these non-verbal cues, what action should the nurse take first?
Continue to observe the client for additional non-verbal behaviors.
Adjust the environment by dimming lights and reducing noise.
Provide reassurance by speaking calmly and maintaining eye contact.
Assess the client's pain level using a non-verbal pain scale.
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.
Ask Bash
Bash is our AI bot, trained to help you pass your exam. AI Generated Content may display inaccurate information, always double-check anything important.
What are some examples of non-verbal pain scales?
Open an interactive chat with Bash
How can I effectively assess a non-verbal patient's pain?
Open an interactive chat with Bash
Why is it important to assess pain before providing reassurance or adjusting the environment?
Open an interactive chat with Bash
NCLEX RN
Psychosocial Integrity
Your Score:
Report Issue
Bash, the Crucial Exams Chat Bot
AI Bot
Loading...
Loading...
Loading...
Nursing and Medical Assistants Package Join Premium for Full Access