The nursing student is obtaining the patient's vital signs (VS). The patient has gone to the clinic seeking help because she is having chest pain. Which of the following vital signs are most important to obtain?
Temperature, pulse, respirations, BP
Temperature, pulse, respirations, BP, pain
BP. respirations, temperature, pulse
Temperature, pulse, respirations, blood pressure, O2 sat, pain
The Correct Answer is D
A. Temperature, pulse, respirations, BP. While these are standard vital signs, they do not include oxygen saturation or pain level, both of which are critical in a patient with chest pain.
B. Temperature, pulse, respirations, BP, pain. Pain is an essential assessment, especially for chest pain, but oxygen saturation should also be measured to assess for hypoxia, which can contribute to cardiac symptoms.
C. BP, respirations, temperature, pulse. This option omits both oxygen saturation and pain level, which are essential in evaluating cardiac and respiratory function in a patient presenting with chest pain.
D. Temperature, pulse, respirations, blood pressure, O2 sat, pain. This option includes all critical assessments for a patient with chest pain. Oxygen saturation helps assess respiratory and circulatory efficiency, and pain assessment is vital in determining the severity and possible cause of the chest pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Errors by the nurse assistant in measuring temperature. While improper technique can lead to inaccurate readings, consistent temperature fluctuations in a head injury patient are more likely due to hypothalamic dysfunction.
B. Increased vasodilatation of the superficial vessels contributing to excess heat losses. Vasodilation can play a role in heat loss, but it does not fully explain difficulty maintaining body temperature, which is primarily regulated by the hypothalamus.
C. The client's head injury causing interference with the function of the hypothalamus. The hypothalamus regulates body temperature, and a severe head injury can disrupt this function, leading to temperature instability (neurogenic fever or hypothermia) despite the absence of infection.
D. Choosing the wrong time of day to obtain vital signs. While body temperature naturally fluctuates throughout the day, major instability in temperature regulation is not due to the timing of measurement but rather an issue with the hypothalamus.
Correct Answer is A
Explanation
A. 104.4°F. This temperature is consistent with heatstroke, a life-threatening condition characterized by hot, dry skin, confusion, and tachycardia. Heatstroke occurs when the body fails to regulate temperature, often exceeding 104°F (40°C).
B. 99.2°F. A temperature of 99.2°F is only slightly elevated and does not match the severe hyperthermia expected in heatstroke.
C. 100.8°F. While this temperature is above normal, it is not high enough to indicate heatstroke, which typically involves temperatures above 104°F.
D. 102.2°F. This temperature suggests heat exhaustion, a milder form of heat-related illness, but heatstroke involves higher temperatures exceeding 104°F.
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.