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

Temperature 96.9°F; pulse 100 bpm; respirations 20 breaths/minute; blood pressure 120/80 mmHg.

Temperature 97.0°F; pulse 54 bpm; respirations 14 breaths/minute; blood pressure 196/114 mmHg.

Temperature 98.6°F; pulse 60 bpm; respirations 14 breaths/minute; blood pressure 110/66 mmHg.

Temperature 99°F; pulse 72 bpm; respirations 16 breaths/minute; blood pressure 100/60 mmHg.

Answer and Explanation

The Correct Answer is B

Temperature 97.0°F; pulse 54 bpm; respirations 14 breaths/minute; blood pressure 196/114 mmHg.

This set of vital signs is cause for concern because the blood pressure is significantly elevated.

A blood pressure reading of 196/114 mmHg is considered a hypertensive crisis and requires immediate medical attention.

Choice A) Temperature 96.9°F; pulse 100 bpm; respirations 20 breaths/minute; blood pressure 120/80 mmHg is within normal limits for an adult.

Choice C) Temperature 98.6°F; pulse 60 bpm; respirations 14 breaths/minute; blood pressure 110/66 mmHg is also within normal limits for an adult.

Choice D) Temperature 99°F; pulse 72 bpm; respirations 16 breaths/minute; blood pressure 100/60 mmHg is slightly elevated but not cause for immediate concern.

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Correct Answer is ["A","B","E"]

Explanation

CHOICE A. It is important to identify yourself when interacting with a client with a visual impairment so that they know who they are speaking with.

CHOICE B. Ensuring adequate lighting can help the client to see better and make use of any remaining vision they may have [B].

CHOICE E. Providing discharge instructions in large print can make it easier for the client to read and understand the information

CHOICE C. Speaking louder is not necessary for clients with visual impairments unless they also have a hearing impairment

CHOICE D. Avoiding talking to other people in the room is not necessary and may make the client feel excluded from the conversation

A. "You have to take these at a certain time, or you will die.". B. "Well, that's your prerogative. Here is the schedule. If you adhere to it, you'll be healthier.". C. Tell me more about that. Let's talk about finding a method that will work for you.". D. "Here is the schedule. Here is a watch. You take these three medications at 8 am, these four at noon, and these three again at 5 pm. At 10 pm, you have these five pills, and you will take them at 3 pm.". E. Aloe promotes wound healing.

Correct Answer is C

Explanation

It is important for the nurse to understand the client’s cultural perspective and work with them to find a method that will help them adhere to their medication schedule.

This approach shows respect for the client’s cultural beliefs and values while also emphasizing the importance of taking their medications on time.

CHOICE A. Telling the client that they will die if they do not take their medications at a certain time is not an appropriate response as it may cause unnecessary fear and anxiety.

CHOICE B. Telling the client that it is their prerogative to follow the schedule or not does not emphasize the importance of adhering to the medication schedule.

CHOICE D. Simply providing the client with a schedule and a watch without discussing their cultural beliefs and values may not be effective in helping them adhere to their medication schedule.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing discharge instructions for a client with a visual impairment. What are appropriate interventions for clients with visual impairments? (Select all that apply).

Correct Answer is ["A","B","E"]

Explanation

Correct Answer is C

Explanation

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