The nurse observes a decrease in a client's level of consciousness. Which vital sign should the nurse obtain first?

Blood pressure.

Temperature.

Respiratory rate.

Pulse rate.

Answer and Explanation

The Correct Answer is C

Choice A: Blood pressure is not the first vital sign to obtain because it is not as sensitive to changes in the level of consciousness as respiratory rate. Blood pressure may be normal or elevated in some cases of decreased consciousness, such as stroke or head injury.

Choice B: Temperature is not the first vital sign to obtain because it is not as relevant to the level of consciousness as respiratory rate. Temperature may be normal or slightly elevated in some cases of decreased consciousness, such as infection or dehydration.

Choice C: Respiratory rate is the first vital sign to obtain because it reflects the adequacy of oxygenation and ventilation, which are essential for brain function. Respiratory rate may be increased, decreased, or irregular in cases of decreased consciousness, depending on the cause and severity.

Choice D: Pulse rate is not the first vital sign to obtain because it is not as indicative of the level of consciousness as respiratory rate. Pulse rate may be normal, fast, or slow in cases of decreased consciousness, depending on the cause and compensatory mechanisms.

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Correct Answer is C

Explanation

Choice A: Regular exercise is a good lifestyle modification, but it is not as important as smoking cessation. Exercise can help lower blood pressure, cholesterol, and weight, but it cannot reverse the damage caused by smoking.

Choice B: Stress reduction is a good lifestyle modification, but it is not as important as smoking cessation. Stress can trigger or worsen cardiac problems, but it cannot cause them as directly as smoking.

Choice C: Smoking cessation is the most important lifestyle modification because smoking is a major risk factor for cardiac disease. Smoking damages the blood vessels, increases blood pressure, reduces oxygen supply, and promotes clot formation.

Choice D: Low-fat diet is a good lifestyle modification, but it is not as important as smoking cessation. A low-fat diet can help lower cholesterol and prevent plaque buildup, but it cannot undo the effects of smoking.

A. Complete an adverse occurrence/incident report. B. Ensure that the restraints are not too tight. C. Demonstrate proper securing of the restraints. D. Initiate the facility’s restraint flow sheet.

Correct Answer is C

Explanation

Choice A: Complete an adverse occurrence/incident report is not the most important action because it does not correct the immediate problem or prevent harm to the client. The nurse should report the incident after ensuring the safety and comfort of the client.
Choice B: Ensure that the restraints are not too tight is an important action, but it is not enough to address the issue of improper securing of the restraints. The nurse should also teach the UAP how to secure the restraints correctly and safely.
Choice C: Demonstrate proper securing of the restraints is the most important action because it educates the UAP and prevents potential complications such as injury, infection, or circulation impairment. The nurse should show the UAP how to secure the restraints to a movable part of the bed frame, not to the rails.
Choice D: Initiate the facility’s restraint flow sheet is an important action, but it is not urgent or critical in this situation. The nurse should document and monitor the use of restraints according to the facility’s policy, but only after ensuring that they are applied correctly and appropriately.

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