Question

client admitted through the emergency department (ed) yesterday with diffuse abdominal pain, nausea, vomiting, fever of 102.6°f (39.2°c), and chills. wbc in the ed was 16,000/mm³ (16 × 10⁹/l). computed tomography (ct) of the abdomen showed widespread inflammation. client underwent an exploratory laparotomy and was diagnosed with a ruptured appendix and peritonitis. right lower quadrant abdominal wound closed with staples and a penrose drain inserted in the lower aspect of the incision. client admitted to medical - surgical unit following surgery. no known allergies (nka). no home medications. which nonverbal behavior observed by the nurse indicates the client may be experiencing acute pain? (select all that apply.) 1. grunting with movement. 2. clenched teeth. 3. grimacing. 4. moaning. 5. restlessness. 6. grabbing abdomen. 7. tightly closed eyes and mouth. 8. avoiding movement.

Explanation:

• Grunting with movement: A nonverbal sign of pain as the body reacts to movement causing discomfort.
• Clenched teeth: A common physical response to pain, showing tension.
• Grimacing: Facial expression indicating pain.
• Grabbing abdomen: Physical gesture to the painful area.
• Tightly closed eyes and mouth: Another sign of tension due to pain.
• Avoiding movement: To prevent increasing pain.

Moaning is a verbal behavior, and restlessness can have other causes like anxiety not just pain.

Answer:

1. Grunting with movement, 2. Clenched teeth, 3. Grimacing, 6. Grabbing abdomen, 7. Tightly closed eyes and mouth, 8. Avoiding movement.