The nurse is caring for a patient who is terminally ill and can no longer speak. Which best indicates that this patient is in pain?
1. Skin is cool and moist to touch.
2. Facial grimacing with moaning when turned
3. Cyanotic feet and lower legs
4. Cheyne-Stokes respiratory pattern
2. Facial grimacing with moaning when turned
Explanation: 1. Cool moist skin may be present in a dying patient but is not a symptom of unrelieved pain.
2. Moaning while being turned and grimacing may indicate pain.
3. Cyanotic feet and lower legs may be present in a dying patient but is not a symptom of unrelieved pain.
4. Cheyne-Stokes respiratory pattern may be present in a dying patient but is not a symptom of unrelieved pain.
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