The nurse is caring for four clients. Which client assessment is the most indicative of having pain?
a. Blood pressure 150/70 mm Hg and sleep-ing
b. Client stating that he is "anxious"
c. Heart rate of 105 beats/min and restless-ness
d. Postoperative client with a neck incision
C
At times clients are unable to verbalize that they are in pain but there are indicators that the client may have acute pain such as increased heart rate, increased blood pressure, increased respirations, sweating, restlessness, and overall distress. All the other distractors could indicate clients who have the potential for being in pain, but restlessness with tachycardia is the most indicative.
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a. beneficence c. teleology b. nonmaleficence d. relativism
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