A nurse is assessing a client who is nonverbal for acute pain.
Which of the following findings is a manifestation of pain?

Choice A rationale:

Allowing extra time to communicate with the client is a crucial action when caring for a client with impaired speech. This approach respects the client's autonomy and ensures that they have the time they need to express themselves. It is an appropriate and compassionate response to the client's condition.

Choice B rationale:

Finishing sentences for the client is not recommended because it interferes with the client's ability to communicate independently. It does not respect the client's autonomy and may lead to frustration.

Choice C rationale:

Avoiding the use of visual aids for communication is not a best practice, especially for clients with impaired speech. Visual aids can enhance communication and should be used when appropriate.

Choice D rationale:

Asking open-ended questions is a good communication strategy, but it is not the first action to take. Allowing extra time for communication should be the initial step when caring for a client with impaired speech.

Choice A rationale:

Clean the client's skin with hot water. Using hot water to clean a client's skin who is incontinent can be harmful. Hot water can damage the skin and exacerbate any existing skin issues. It is essential to use lukewarm water and gentle, pH-balanced cleansers to prevent skin irritation.

Choice B rationale:

Dry between folds in the client's skin. This is the correct answer. When caring for a client who is incontinent, it is crucial to ensure that the skin is kept clean and dry. Moisture between skin folds can lead to skin breakdown and the development of pressure ulcers. Drying the skin thoroughly helps prevent these issues.

Choice C rationale:

Apply baby powder to the client's skin. Applying baby powder is not recommended, as it can create a moist environment that may promote the growth of fungi and bacteria. It can also potentially lead to respiratory issues if the client inhales the powder. It's better to focus on keeping the skin clean and dry without using powder.

Choice D rationale:

Restrict the client's fluid intake. Restricting the client's fluid intake is not a suitable approach. Adequate hydration is essential for overall health and well-being. Dehydration can lead to various complications and negatively impact the client's overall health. Instead, focus on managing incontinence through appropriate hygiene and the use of incontinence products. .