One of the main methods to obtain a good health assessment is to obtain vital signs. Of which of the listed descriptions below is not a use of obtaining vital signs?
Pain rating is often included as a vital sign that is subjective in nature.
In the less stable client, it is advised to check the vital signs once a day or as needed.
Vital signs help assess the effectiveness of the client’s circulatory, neurological, endocrine, and respiratory systems.
Vital signs include temperature, pulse, respirations, blood pressure, and pulse oximeter.
The Correct Answer is B
Choice A reason: Pain rating is considered a subjective vital sign, assessed via patient self-reporting, often on a 0-10 scale. It reflects neurological and emotional status, guiding pain management. Including it as a vital sign is a valid clinical practice, making this choice a correct use.
Choice B reason: In less stable clients, vital signs should be checked more frequently than once daily, often every few hours, to monitor deteriorating conditions like sepsis or shock. This statement inaccurately suggests infrequent monitoring, which is not a standard use of vital signs, making it the correct answer.
Choice C reason: Vital signs assess circulatory (blood pressure, pulse), respiratory (respirations, pulse oximetry), neurological (via pulse and responsiveness), and endocrine (temperature) systems. They provide critical data on physiological function, making this a valid use of vital signs in comprehensive health assessments.
Choice D reason: Vital signs include temperature, pulse, respirations, blood pressure, and pulse oximetry, which measure thermoregulation, cardiovascular, and respiratory status. This is a standard definition in clinical practice, accurately reflecting the components of vital sign assessment, making it a correct use.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Normal blood pressure is <120/<80 mmHg, far below 148/92 mmHg, which is stage 2 hypertension per AHA guidelines. Assuming normal misclassifies the reading, risking untreated hypertension, leading to complications like stroke or heart failure. Accurate classification ensures proper management with lifestyle changes or medications.
Choice B reason: Stage 1 hypertension is 130-139/80-89 mmHg, lower than 148/92 mmHg, which is stage 2. Misclassifying as stage 1 underestimates severity, potentially delaying aggressive treatment like dual antihypertensives. Correct staging ensures timely intervention, critical for preventing cardiovascular damage in patients with elevated blood pressure readings.
Choice C reason: Stage 2 hypertension, per AHA, is ≥140/≥90 mmHg, matching 148/92 mmHg. This requires immediate lifestyle changes and likely medications to prevent cardiovascular events. Accurate classification guides treatment, ensuring blood pressure control, reducing risks of stroke, heart attack, or kidney damage in patients with significant hypertension.
Choice D reason: Elevated blood pressure is 120-129/<80 mmHg, below 148/92 mmHg, which is stage 2 hypertension. Assuming elevated underestimates the condition, risking inadequate intervention and progression to organ damage. Correct classification ensures appropriate management, critical for controlling hypertension and preventing long-term complications in affected patients.
Correct Answer is C
Explanation
Choice A reason: Measuring pulse for 15 seconds and multiplying by 4 assumes a regular rhythm, which is inaccurate for an irregular pulse. Irregular rhythms, such as atrial fibrillation, require longer measurement to capture variability in heartbeats, ensuring an accurate rate. This method risks over- or underestimating the true pulse rate.
Choice B reason: Counting for 30 seconds and multiplying by 2 is insufficient for an irregular pulse, as it may miss variations in heart rate, common in arrhythmias. Accurate assessment of irregular rhythms, like premature ventricular contractions, demands a full minute to account for fluctuations, making this method less reliable.
Choice C reason: Measuring the pulse for 60 seconds is the standard for irregular rhythms, as it captures the full range of heart rate variability. Conditions like atrial fibrillation cause inconsistent beats, and a full minute ensures accuracy in counting, aligning with clinical guidelines for assessing cardiovascular status in such cases.
Choice D reason: Counting for 45 seconds and multiplying by 2 is not a standard practice for irregular pulses. It fails to account for the full variability in heart rate, potentially skewing results in conditions like arrhythmias. A 60-second count is necessary for precision in irregular rhythm assessments.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.