5The nurse is caring for a client who is sedated and on the ventilator in ICU. The family expresses concern about controlling the client’s pain when he cannot speak. The nurse explains that assessing pain in a nonverbal client involves watching for which of the following signs? Select all that apply.
grabbing at the bed rails biting the ventilator tubing facial grimacing stiffness or rigidity of the body decreased urinary output increased blood pressure and ...