What does a RASS score of +4 indicate?

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

Answer: (B)

The RASS measures how awake and agitated a patient is, from deeply sedated to fully alert and calm, with positive numbers indicating agitation. A score of +4 is the highest level of agitation on the scale and means the patient is combative or violent with immediate danger to staff or others. This level flags a serious safety risk and typically prompts urgent de-escalation efforts and possible sedation or escalation of care with the medical team. The other states describe milder agitation or sedation (for example, +3 is very agitated but not necessarily combative, +2 is agitated, +1 is restless, and 0 is alert and calm).