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.
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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: The trigeminal nerve (V) controls facial sensation and chewing, not smell, which is governed by the olfactory nerve (I). Misidentifying this risks incorrect neurological assessment, potentially missing olfactory deficits indicating brain injury or tumors, critical for accurate diagnosis and management in patients with sensory complaints.
Choice B reason: The optic nerve (II) governs vision, not smell, which is the olfactory nerve’s function (I). Assuming optic involvement misguides cranial nerve assessment, risking oversight of olfactory dysfunction, which may signal neurological conditions like Parkinson’s or trauma, requiring targeted evaluation and intervention in clinical practice.
Choice C reason: The olfactory nerve (I) is responsible for the sense of smell, transmitting sensory input from the nasal mucosa to the brain. Accurate identification ensures proper neurological assessment, detecting deficits that may indicate trauma, tumors, or neurodegenerative diseases, guiding diagnosis and treatment in patients with smell-related complaints.
Choice D reason: The vestibulocochlear nerve (VIII) controls hearing and balance, not smell, which is the olfactory nerve’s role (I). Misidentifying this risks incorrect assessment, potentially overlooking olfactory issues signaling neurological pathology, delaying diagnosis and management critical for addressing sensory deficits in clinical neurological evaluations.
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