The nurse is performing an abdominal assessment on a client. During the focused interview, the client tells the nurse about experiencing some abdominal pain recently
As the nurse assesses the client, which behaviors indicate that the client may be experiencing pain or anxiety during the examination?
Select all that apply.
1. The client's respiratory rate is 26 per minute.
2. The client moves away from the nurse's hands.
3. The client grimaces.
4. The client pulls his knees toward his stomach.
5. The client coughs loudly.
Correct Answer: 1, 2, 3, 4
If the client's respiratory rate increases during the examination, it may indicate that the client is experiencing pain or anxiety. The client may move away from the nurse during the examination if the client is experiencing pain. Grimacing is a facial expression that can indicate that the client is experiencing pain during the assessment. The client who exhibits guarding behavior is most likely experiencing pain. The client who coughs loudly is not necessarily experiencing pain. This is not a typical expression of pain or anxiety.
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