What does a RASS score of +1 indicate?

• A. Alert and calm
• B. Restless, anxious, apprehensive but not yet agitated
• C. Combative, violent, immediate danger to self or others
• D. Very agitated, aggressive, concern for future violence

Answer: (B)

RASS measures agitation and sedation on a scale from -5 to +4. Positive numbers mean increasing agitation, while 0 is calm and alert. A score of +1 corresponds to mild agitation: the patient is restless, anxious, and apprehensive but not yet agitated. This is why the description "Restless, anxious, apprehensive but not yet agitated" fits best. If agitation increases, the numbers rise (for example, +2 is agitated, +3 very agitated, +4 combative). The other descriptions describe calmer or more dangerous states.