During an assessment, a ventilated patient begins to frown and wiggle about in bed. Which assessment strategy would be most helpful for the nurse to validate these observations?

Question

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1. The Glasgow Coma Scale will identify the level of consciousness present to evaluate the sedation level that is used with patients who are intubated. But this scale does not identify the source of the problem that has increased the patient's facial changes or movement.
2. Maslow's hierarchy of needs prioritizes needs based on essential to higher-level functions in the body; it would not help identify the source of the changes noted in the patient.
3. The CPOT pain scale will identify if pain is present and the degree of effectiveness of drug management in a patient who cannot speak due to intubation.
4. Vital signs might tell the nurse that a change has occurred, but they do not indicate the source of the discomfort or problem.

During an Assessment, a Ventilated Patient Begins to Frown and Wiggle