The nurse is performing a pain assessment on a client who is unable to communicate verbally. Which vital sign data would indicate that the client is in acute pain? Select all that apply
1. Temperature of 100.6 degrees.
2. Pulse rate 94.
3. Respiratory rate 32.
4. Blood pressure 158/92 mmHg.
5. Facial grimacing.
Correct Answer: 2, 3, 4, 5
The client may be diaphoretic with acute pain, but not directly as a result of a low-grade temperature. 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. Facial grimacing may be noted in the expressions of the client experiencing acute pain.
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