A nurse is getting a client out of bed to ambulate for the first time.

The client is pale, diaphoretic, has a pulse of 100/minute, and says, “I feel weak.

Let me sit on the side of the bed for a minute.” What finding should the nurse document?

A client who grimaces during a dressing change is showing a nonverbal sign of pain. Grimacing is an expression of facial muscles that indicates discomfort or distress.

The nurse should record this as a symptom of pain and ask the client to rate the pain using a numeric or visual scale.

Choice B is wrong because an elevated heart rate while exercising is not necessarily a symptom of pain. It could be a normal response to increased physical activity or a sign of other conditions such as anxiety, dehydration, or fever.

Choice C is wrong because crying during a procedure is not a reliable indicator of pain. Crying is an emotional response that can be influenced by many factors such as fear, stress, or sadness.

The nurse should not assume that the client is in pain based on crying alone and should ask the client about the reason for crying and the level of pain.

Choice D is wrong because saying “I feel achy all over” is not a specific description of pain.

Aching is a vague term that can refer to different sensations such as soreness, stiffness, or cramping.

The nurse should ask the client to clarify what kind of pain they are feeling, where it is located, how severe it is, and what makes it better or worse.

The nurse should respect the client’s privacy and confidentiality by not discussing the client’s condition in a crowded elevator, even with the health care provider. The nurse should suggest a more private area to have the conversation.

Choice A is wrong because it shows a lack of professionalism and accountability. The nurse should be able to provide a brief update on the client’s status to the health care provider, even if the nurse is off duty.

Choice B is wrong because it implies that the healthcare provider does not have the right to access the client’s information, which is not true. The health care provider is part of the health care team and has a legitimate need to know the client’s condition.

Choice D is wrong because it violates the client’s privacy and confidentiality by disclosing sensitive information in front of other people. The nurse should not share any details about the client’s condition or treatment without the client’s consent or unless it is necessary for the client’s care.