What does a RASS score of +2 indicate?

• A. Restless, anxious, apprehensive but not yet agitated
• B. Alert and calm
• C. Combative, violent, immediate danger to self or others
• D. Agitated, mild agitation but not yet aggressive

Answer: (D)

Positive values on the RASS indicate agitation, with higher numbers meaning more agitation. A score of +2 means the person is agitated but not aggressive or dangerous yet: they are awake and active, likely restless or fidgety, possibly loud or trying to sit up or move around, but not displaying combative behavior. This level guides how you respond—using calm verbal de-escalation, ensuring comfort and safety, and addressing possible causes like pain, discomfort, or environmental triggers. The other states described map to different levels: +1 is restless but not yet agitated, 0 is calm, and +4 is combative or violent.