The practical nurse (PN) is assisting with blood pressure measurement for adults at a community health fair. Which blood pressure measurement requires the most immediate action by the PN?

Choice A reason: While respiratory rate is an important vital sign to monitor, changes in respiratory rate are not the most critical indicator of an imminent complication related to an abdominal aneurysm. Respiratory rate can be influenced by various factors such as pain, anxiety, or underlying respiratory conditions. However, it does not directly correlate with the risk of aneurysm rupture, which is the primary concern in clients with an abdominal aneurysm.
Choice B reason: Urinary output is an important indicator of renal function and overall fluid balance. However, changes in urinary output are not the most immediate concern in the context of an abdominal aneurysm. While it is essential to monitor urine output to ensure adequate kidney function, it is not the primary parameter that would signal an imminent complication or rupture of the aneurysm.
Choice C reason: Temperature can provide valuable information about the presence of an infection or systemic inflammation. However, changes in temperature are not directly related to the risk of aneurysm rupture. Although an elevated temperature may warrant further investigation, it is not the most critical finding to report in the context of an abdominal aneurysm.
Choice D reason: Blood pressure is the most important assessment finding to monitor and report in a client with an abdominal aneurysm. Elevated blood pressure can increase the risk of aneurysm rupture due to the added stress on the arterial wall. Conversely, a sudden drop in blood pressure can indicate a potential rupture or internal bleeding, which is a medical emergency. Monitoring and reporting changes in blood pressure are crucial in providing timely interventions to prevent or address complications related to an abdominal aneurysm.

Choice A reason: Hematemesis, or vomiting of blood, is a critical symptom to monitor in a client with esophageal varices. Esophageal varices are enlarged veins in the esophagus that can rupture and bleed due to increased pressure in the portal venous system, a common complication of cirrhosis. Hematemesis indicates a potentially life-threatening variceal bleed that requires immediate medical intervention. Reporting this finding promptly ensures that the healthcare team can take swift action to manage the bleeding and stabilize the client.
Choice B reason: Anorexia, or loss of appetite, is a common symptom in clients with chronic liver disease, including cirrhosis. While it is important to address nutritional concerns, anorexia does not directly indicate a life-threatening complication like variceal bleeding. Monitoring for anorexia is essential for overall health and nutritional support, but it is not the most immediate concern in this scenario.
Choice C reason: Clay-colored stools can indicate a lack of bile in the stool, which may occur due to biliary obstruction or impaired bile flow. While this finding is significant and requires attention, it is not as urgent as hematemesis in the context of esophageal varices. Clay-colored stools may suggest other complications related to liver function but do not indicate an immediate life-threatening situation.
Choice D reason: Brown, foamy urine may indicate the presence of blood or protein in the urine, which can occur in various kidney and urinary tract disorders. While this finding is important to monitor, it is not directly related to esophageal varices or their complications. The primary concern with esophageal varices is the risk of bleeding, which is best indicated by hematemesis.