You are the nurse caring for the 25-year-old victim of a motor vehicle accident with a fractured pelvis and a ruptured bladder
The nurse's aide (NA) tells you that she is concerned because the patient's resting heart rate is 110 beats per minute, her respirations are 24 breaths per minute, temperature is 99.1°F axillary, and the blood pressure is 125/85 mm Hg. What other information is most important as you assess this patient's physiologic status?
A) The patient's understanding of pain physiology
B) The patient's serum glucose level
C) The patient's white blood cell count
D) The patient's rating of her pain
Ans: D
Feedback:
The nurse's assessment of the patient's pain is a priority. There is no suggestion of diabetes and leukocytosis would not occur at this early stage of recovery. The patient does not need to fully understand pain physiology in order to communicate the presence, absence, or severity of pain.
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