A terminally ill patient is unconscious. Which nursing assessment findings would the nurse evaluate as possible pain responses? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply
1. The patient's breathing pattern changes.
2. The patient becomes diaphoretic.
3. It is unlikely that the unconscious patient will experience pain.
4. Agitation will begin or will increase.
5. Facial grimacing will occur with movement.
1,2,4,5
Rationale 1: Changes in breathing pattern such as guarding respirations may indicate pain. An increase or decrease in respiratory rate may also indicate pain.
Rationale 2: Diaphoresis may indicate pain.
Rationale 3: The unconscious patient may have severe pain and be unable to verbally communicate its presence to the nurse.
Rationale 4: Restlessness, agitation, and inability to lie still may all indicate pain.
Rationale 5: Facial grimacing is a common indicator of pain.
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