The nurse is caring for a client who presented to the emergency room with BP of 138/90, HR of 110, O2 Sat of 95%, Temp of 38°C, and abdominal pain level of 7/10. Which of the above vital signs would the nurse address first?

Blood pressure of 138/90

Heart rate 110 beats per minute

O2 Sat of 95%

Temperature 38°C

Answer and Explanation

The Correct Answer is B

A reason:

A blood pressure of 138/90 is elevated but not immediately life-threatening. It is important to monitor, but it is not the highest priority in this situation.

B reason:

A heart rate of 110 beats per minute is the most concerning and should be addressed first. Tachycardia can indicate pain, fever, or other underlying issues that need prompt attention.

C reason:

An O2 Sat of 95% is within normal limits and is not an immediate concern compared to the other vital signs presented.

D reason:

A temperature of 38°C indicates a fever, which needs to be addressed, but the elevated heart rate takes priority as it can have more immediate implications for the client's condition.

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

Explanation

A reason:

Ignoring the urge to defecate is a common cause of constipation. Suppressing the natural urge can lead to harder stools and decreased bowel movement regularity.

B reason:

Inadequate fluid intake contributes to constipation by leading to harder stools that are more difficult to pass. Sufficient hydration is essential for maintaining regular bowel movements.

C reason:

Decreased fiber in the diet is a significant cause of constipation. Fiber helps to bulk up the stool and promote regular bowel movements. A diet low in fiber can result in harder and less frequent stools.

D reason:

Increased activity typically promotes regular bowel movements and is not a cause of constipation. Physical activity stimulates intestinal motility, helping to prevent constipation.

E reason:

Excessive laxative use can lead to dependence and decreased bowel motility over time, causing constipation. Overuse of laxatives can disrupt the natural bowel rhythm and lead to chronic constipation.

A. More difficulty seeing due to a greater sensitivity to glare B. Decreased cough reflex C. Decreased systolic blood pressure D. Decreased bladder capacity E. Dehydration of intervertebral discs

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

Explanation

A reason:

More difficulty seeing due to a greater sensitivity to glare is a common change with aging. The lens of the eye becomes less flexible and more prone to glare.

B reason:

A decreased cough reflex is typical in older adults, making them more susceptible to respiratory infections and complications.

C reason:

Decreased systolic blood pressure is not a common change with aging. Instead, systolic blood pressure often increases due to decreased elasticity of blood vessels.

D reason:

Decreased bladder capacity is a normal part of aging, leading to increased frequency of urination and sometimes incontinence.

E reason:

Dehydration of intervertebral discs occurs with aging, leading to reduced height and potential for back pain and decreased mobility.

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The nurse is caring for a client who presented to the emergency room with BP of 138/90, HR of 110, O2 Sat of 95%, Temp of 38°C, and abdominal pain level of 7/10. Which of the above vital signs would the nurse address first?

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

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