The nurse knows the importance of assessing vital signs is to:

Evaluate the client's responses to treatment.

Carry out orders from the healthcare provider.

Monitor risks for alterations in health.

Establish a baseline.

Answer and Explanation

Correct Answer : A,C,D

Choice A Reason:
Assessing vital signs is crucial for evaluating the client's responses to treatment. Changes in vital signs can indicate whether the body is responding positively or negatively to a treatment, allowing healthcare providers to adjust care plans accordingly. For example, a decrease in fever after administering antipyretics would suggest the treatment is effective.

Choice B Reason:
While carrying out orders from the healthcare provider is a responsibility of the nurse, it is not the primary reason for assessing vital signs. Vital signs are assessed to inform clinical decisions, not solely to fulfill orders. Therefore, this choice is not correct in the context of the importance of vital sign assessment.

Choice C Reason:
Monitoring risks for alterations in health is another key reason for assessing vital signs. Vital signs can serve as early indicators of health issues, such as the onset of an infection indicated by a rising temperature or cardiovascular problems suggested by changes in blood pressure or heart rate.

Choice D Reason:
Establishing a baseline is essential when assessing vital signs. It provides a reference point for future comparisons, which is important for detecting any deviations from the client's normal range. This helps in identifying potential health issues early and monitoring the progression of known conditions.

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Correct Answer is D

Explanation

The correct answer is d) Stage II.
Choice a reason:
Stage IV pressure ulcers are the most severe, with full-thickness skin loss and exposed bone, tendon, or muscle. Signs of stage IV include large-scale tissue loss, possibly including slough or eschar, and may include undermining and tunneling. The scenario described does not indicate such an advanced stage, as there is no mention of exposed deeper tissues or structures.
Choice b reason:
Stage III pressure ulcers involve full-thickness skin loss, potentially affecting subcutaneous tissue but not extending to underlying muscle or bone. The wound may have a crater-like appearance. The described condition does not match stage III, as there is no indication of the ulcer extending into subcutaneous tissue.
Choice c reason:
Stage I pressure ulcers present with intact skin and non-blanchable redness of a localized area usually over a bony prominence. The skin may be painful, firm, soft, warmer, or cooler compared to adjacent tissue. In the given scenario, the skin is not intact, ruling out stage I.
Choice d reason:
Stage II pressure ulcers are characterized by partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. They may also present as intact or ruptured blisters. The description of the skin condition with erythema, serosanguineous drainage, and a blister-like appearance aligns with a stage II pressure ulcer.

A. Resonance B. Tympanic C. Flat D. Dullness

Correct Answer is A

Explanation

Choice a reason:
Resonance is the expected percussion note when percussing over normal, healthy lung tissue. This sound is produced due to the presence of air in the lung parenchyma, which allows for the transmission of sound waves through the air-filled spaces. In a healthy individual, the resonance indicates that the lungs are free from any significant abnormalities that could alter the sound, such as fluid or solid masses.
Choice b reason:
Tympanic notes are typically heard over hollow, air-containing structures like the stomach. This sound is not expected in lung percussion unless there is a large, air-filled cavity within the lung tissue, which would be abnormal and indicative of a pathological condition such as a pneumothorax.
Choice c reason:
A flat percussion note is usually heard over dense tissues where air is not present, such as over the thigh muscles or areas of the chest where lung tissue has been replaced by something more solid, like in the case of a pleural effusion or a lung mass.
Choice d reason:
Dullness on percussion usually indicates that the lung is not air-filled and may be suggestive of underlying conditions such as pneumonia, tumor, or atelectasis. It is a higher-pitched sound compared to flatness and is typically found in areas of the lung that are filled with fluid or solid tissue rather than air.

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The nurse knows the importance of assessing vital signs is to:

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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