A nurse is obtaining a client's vital signs. Which of the following findings should the nurse report to the charge nurse?

Heart rate 98/min

Temperature 38.0 °C (100.4 °F)

Respiratory rate 14/min

Blood pressure 142/88 mm Hg

Answer and Explanation

The Correct Answer is B

A. Heart rate 98/min. A heart rate of 98 beats per minute is within the normal range for adults, which is typically between 60 and 100 beats per minute. Therefore, this finding does not require reporting.
B. Temperature 38.0 °C (100.4 °F). A temperature of 38.0 °C (100.4 °F) is considered a low-grade fever and may indicate an infection or other underlying condition. This finding should be reported to the charge nurse for further assessment and potential intervention.
C. Respiratory rate 14/min. A respiratory rate of 14 breaths per minute is within the normal range for adults, which is generally between 12 and 20 breaths per minute. This finding does not require reporting.
D. Blood pressure 142/88 mm Hg. A blood pressure reading of 142/88 mm Hg is classified as elevated or stage 1 hypertension. While it is important to monitor blood pressure, this finding may not require immediate reporting unless there are additional concerning symptoms or a significant change from the client's baseline readings.

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Correct Answer is B

Explanation

A. Cottage cheese: Cottage cheese is low in fiber and does not promote bowel regularity. A diet high in fiber is recommended to help soften stool and stimulate peristalsis, which is necessary for relieving constipation.
B. Bran muffin: Bran is an excellent source of dietary fiber, which adds bulk to stool and facilitates easier bowel movements. High-fiber foods, such as whole grains, fruits, and vegetables, are essential in managing constipation effectively.
C. Tomato juice: While tomato juice contains some nutrients, it is not a significant source of fiber. Increasing fiber intake is more beneficial for constipation than consuming low-fiber liquids. However, adequate hydration is still important in preventing hard stools.
D. Puffed rice cereal: Puffed rice cereal is typically refined and low in fiber, making it a poor choice for relieving constipation. Whole grains, such as bran, oatmeal, or whole wheat products, are more effective in promoting bowel regularity.

A. Believes that his brother's death will be reversible B. Believes his bad behavior is causing his brother's death C. Alienates himself from his peers D. Regresses to an earlier developmental level

Correct Answer is B

Explanation

A. Believes that his brother's death will be reversible. This response is more typical of preschool-aged children (ages 3 to 5), who often perceive death as temporary or reversible, similar to sleep or separation. School-age children, however, begin to understand the finality of death, though they may still struggle with its implications.
B. Believes his bad behavior is causing his brother's death. School-age children (ages 6 to 12) often engage in magical thinking and may believe that their actions, thoughts, or behaviors are responsible for events, including illness and death. They may feel guilt and self-blame, thinking that past misbehavior contributed to their sibling's condition. Providing reassurance and education about the medical causes of the illness can help alleviate these feelings.
C. Alienates himself from his peers. While social withdrawal can occur in grieving children, school-age children typically seek peer support and may use friendships as a coping mechanism. Alienation is more commonly seen in adolescents, who might isolate themselves due to difficulty expressing emotions or fear of burdening others.
D. Regresses to an earlier developmental level. Regression, such as bedwetting, clinging behavior, or baby talk, is more commonly seen in younger children, particularly toddlers and preschoolers, when they experience stress or grief. School-age children are more likely to express distress through guilt, sadness, or behavioral changes rather than regression.

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A nurse is obtaining a client's vital signs. Which of the following findings should the nurse report to the charge nurse?

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