A nurse is monitoring a postoperative client who is unable to respond to questions. Which of the following nonverbal behaviors should the nurse identify as an indication that the client is experiencing pain? (Select all that apply)

Choice A reason: Wearing gloves when measuring a client's blood pressure is not typically necessary unless there is a risk of exposure to bodily fluids or if the client has an infectious disease. The use of gloves is based on the type of contact and potential for exposure, not routine tasks like BP measurement.

Choice B reason: Wearing gloves for all client contact is not necessary and is not consistent with standard precautions. Gloves should be used when there is potential contact with blood, body fluids, secretions, excretions, contaminated items, or mucous membranes.

Choice C reason: Gloves are not a substitute for hand hygiene. The primary reason for wearing gloves is to provide a barrier against infection, not to reduce handwashing. Hand hygiene is still required before donning gloves and after removing them, regardless of whether the gloves are soiled or not.

Choice D reason: Wearing gloves and a gown when bathing a client with open skin lesions is correct because it protects both the healthcare worker and the client from the risk of infection. Open skin lesions can be a source of infection, and PPE is necessary to prevent the transmission of pathogens.

Choice A reason: The severity of the condition may not always correlate with the level of pain experienced by the client. Pain is a subjective experience, and two individuals with the same condition may report different levels of pain.

Choice B reason: Vital signs can be indicators of pain but are not always reliable. For example, some clients may exhibit increased heart rate or blood pressure when in pain, while others may not show significant changes in vital signs despite severe pain.

Choice C reason: Nonverbal behavior can be an indicator of pain, especially in clients who are unable to communicate verbally. However, it is still considered less reliable than self-report because it is subject to interpretation by the observer.

Choice D reason: Self-report of pain is considered the most reliable indicator of a patient's pain experience. It is a direct expression of the client's experience and should be the primary source of assessment whenever possible.