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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Bounding pulses are not a sign of inadequate perfusion.
Inadequate perfusion is when blood flow to a specific part of your body is reduced and that part will not receive essential nutrients.
Signs of inadequate perfusion include cyanosis (bluish discoloration of the skin due to lack of oxygen), pallor (paleness of the skin), and coolness1.
Choice B is incorrect because cyanosis is a sign of inadequate perfusion.
Choice C is incorrect because pallor is a sign of inadequate perfusion.
Choice D is incorrect because coolness is a sign of inadequate perfusion.
Correct Answer is B
Explanation
Tell me more about it.” This statement acknowledges the difficulty of the situation and invites the patient to share their feelings and thoughts.
Choice A is incorrect because it does not acknowledge the patient’s current feelings and offers false reassurance.
Choice C is incorrect because it does not acknowledge the patient’s current feelings and may come across as intrusive.
Choice D is incorrect because it does not acknowledge the patient’s current feelings and offers false reassurance.
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