The nurse is performing a physical assessment on a client with undiagnosed back pain. The client is unable to communicate verbally
Which of the following vital sign values would indicate to the nurse that the client is in acute pain? Standard Text: Select all that apply. 1. Temperature of 100.6 degrees:
2. Pulse rate 94
3. Respiratory rate 32
4. Blood pressure 158/92
5. Facial grimacing
2,3,4,5
Rationale 1: Temperature of 100.6 degrees. The client may be diaphoretic with acute pain, but not directly as a result of a low-grade temperature.
Rationale 2: Pulse rate 94. When in acute pain, a client will typically have sympathetic nervous system responses that are exhibited in an increased pulse, respiratory rate, and blood pressure.
Rationale 3: Respiratory rate 32. When in acute pain, a client will typically have sympathetic nervous system responses that are exhibited in an increased pulse, respiratory rate, and blood pressure.
Rationale 4: Blood pressure 158/92. When in acute pain, a client will typically have sympathetic nervous system responses that are exhibited in an increased pulse, respiratory rate, and blood pressure.
Rationale 5: Facial grimacing. Facial grimacing may be noted in the expressions of the client experiencing acute pain.
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