The nurse is most concerned about which of these findings in a client with systemic lupus erythematosus (SLE)?

Choice A reason: Properly disposing of contaminated equipment is an important infectioncontrol measure, but it is not the most effective way to prevent the spread of pathogens during client care. Contaminated equipment, such as gloves, gowns, masks, or needles, should be disposed of in designated containers or bags to prevent exposure or injury to others. However, this measure does not eliminate the risk of transmission of pathogens from the hands of the health care worker to the client or the environment.

Choice B reason: Discarding used syringes into appropriate containers is an important infectioncontrol measure, but it is not the most effective way to prevent the spread of pathogens during client care. Used syringes, especially those that contain blood or body fluids, should be discarded into punctureresistant, leakproof, and labeled containers to prevent needlestick injuries or exposure to others. However, this measure does not eliminate the risk of transmission of pathogens from the hands of the health care worker to the client or the environment.

Choice C reason: Changing soiled linens is an important infectioncontrol measure, but it is not the most effective way to prevent the spread of pathogens during client care. Soiled linens, especially those that contain blood or body fluids, should be changed and handled with gloves and minimal agitation to prevent contamination or aerosolization of pathogens. However, this measure does not eliminate the risk of transmission of pathogens from the hands of the health care worker to the client or the environment.

Choice D reason: Performing hand hygiene is the most effective way to prevent the spread of pathogens during client care, because it reduces the number of microorganisms on the hands of the health care worker, which are the most common source and mode of transmission of infection. Hand hygiene should be performed before and after contact with the client, after contact with potentially infectious materials, after removing gloves, and before and after performing invasive procedures. Hand hygiene can be performed by washing with soap and water or using alcoholbased hand rubs.

Choice A reason: Increased agitation is a nonverbal sign of pain, because it indicates that the client is restless, uncomfortable, or distressed by the pain. Agitation can manifest as fidgeting, tossing, turning, moaning, or groaning.

Choice B reason: Decreased attention span is not a nonverbal sign of pain, but rather a cognitive or behavioral sign of pain. Decreased attention span means that the client has difficulty focusing, concentrating, or remembering things, which can be affected by pain. However, decreased attention span is not a direct expression of pain, but rather a consequence of pain.

Choice C reason: Grimacing is a nonverbal sign of pain, because it indicates that the client is experiencing facial muscle tension, contraction, or distortion due to the pain. Grimacing can manifest as frowning, wrinkling the forehead, pursing the lips, or clenching the teeth.

Choice D reason: Reported pain of 5/10 is not a nonverbal sign of pain, but rather a verbal sign of pain. Reported pain of 5/10 means that the client has communicated the intensity of their pain using a numerical scale, which is a subjective and selfreported measure of pain. However, reported pain of 5/10 is not a direct expression of pain, but rather a description of pain.

Choice E reason: Increase in heart rate is a nonverbal sign of pain, because it indicates that the client is experiencing physiological changes due to the pain. Increase in heart rate can manifest as tachycardia, palpitations, or arrhythmias.