Which set of vital signs, taken on an adult, is cause for concern and requires further evaluation?

The best intervention by the nurse to prevent further skin and tissue breakdown on a reddened area on a client’s right heel is to relieve pressure from the right heel1.

Heels are particularly vulnerable to skin breakdown and when patients lie supine, all of the pressure of their lower legs and feet rest on the heels1.

Preventing heel ulcers primarily involves the use of simple devices, like pillows and offloading devices, to protect delicate heels1.

Choice A is not correct because documenting the reddened area alone will not prevent further skin and tissue breakdown.

Choice B is not correct because asking the client how the area became reddened alone will not prevent further skin and tissue breakdown.

Choice C is not correct because assessing the client’s diet alone will not prevent further skin and tissue breakdown.

According to Maslow’s Hierarchy of Needs, all people have basic human needs that must be met before they can attend to higher needs.

These basic human needs are physiological (food and clothing), safety (job security), love and belonging needs (friendship), esteem, and self-actualization1.

Choice A is incorrect because people do not have the same needs at the same time.

Choice B is incorrect because Maslow’s Hierarchy of Needs does not mention the risk of becoming ill.

Choice C is incorrect because not all people have a desire to be the best.