Which of the following statements by the nurse reflects a need for imm

Which of the following statements by the nurse reflects a need for immediate follow-up regard-ing the physical effects of chronic pain on body function?

1. “His pulse and blood pressure are within his normal baseline limits, so I’m sure the pain medication is working.”
2. “Please take his pulse and blood pressure, and let me know if they are elevated above his normal baselines.”
3. “If his pulse and blood pressure are above his normal baseline, let me know, and I will medicate him for pain.”
4. “Unmanaged pain usually manifests itself in both an elevated pulse and blood pressure.”

ANSWER

ANS: 1
Except in cases of severe traumatic pain, which sends a person into shock, most people reach a level of adaptation in which physical signs return to normal. Thus clients in pain will not always have changes in their vital signs. Changes in vital signs are more often indicative of problems other than pain. Although the remaining options recognize the phenomena, they are not assuming that no elevation of vital signs means the absence of pain.