If the trauma client was experiencing pain, the nurse may assess which of the following objective data?
1. Facial grimacing and change in blood pressure or pulse
2. Flushed skin on neck and face, bradycardia
3. Hyperactive deep tendon reflexes and gripping hands
4. Increased anxiety and verbalizing "impending doom"
Facial grimacing and change in blood pressure or pulse
Rationale: Facial grimacing and changes in breathing pattern, blood pressure, and pulse along with diaphoresis and agitation are objective signs of pain. The patient will be in tachycardia. With acute pain the deep tendon reflexes will not be affected. Patients with pain have increased anxiety but usually do not verbalize "impending doom.". Patients experiencing and internal hemorrhage or a cardiac abnormality many times verbalize "impending doom" comments such as "I'm going to die.".
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A school nurse reviews the standards of professional practice published by the NASN. Which professional standard will the school nurse rely upon when providing care?
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