Which of these vital signs—BP would you report to the doctor?
90/60
125/68
144/76
150/70
The Correct Answer is A
Choice A reason: A blood pressure of 90/60 mmHg is hypotensive, indicating potentially inadequate perfusion to organs, which may result from dehydration, shock, or medication effects. This reading is concerning and requires reporting to the doctor for further evaluation and management to prevent complications like organ failure.
Choice B reason: A blood pressure of 125/68 mmHg is within normal to slightly elevated ranges, not immediately concerning. It does not warrant urgent reporting unless accompanied by symptoms or trends suggesting instability, as it aligns with typical adult values under most clinical guidelines.
Choice C reason: A blood pressure of 144/76 mmHg is elevated but not critical unless persistent or symptomatic. It suggests prehypertension or early hypertension, which may need monitoring but not immediate reporting unless other clinical factors, like symptoms or patient history, indicate urgency.
Choice D reason: A blood pressure of 150/70 mmHg is elevated, indicating possible hypertension, but not an emergency unless accompanied by symptoms like chest pain. It requires monitoring rather than immediate reporting, as it falls short of hypertensive crisis thresholds like 180/120 mmHg.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Abdominal distention is an unexpected finding, potentially indicating serious issues like bowel obstruction, ascites, or organ enlargement, requiring urgent reporting. Unlike normal findings like symmetry, distention demands investigation. Prompt documentation ensures timely diagnosis and intervention, critical for preventing complications in patients with abdominal abnormalities.
Choice B reason: Silver striae are expected from skin stretching (e.g., pregnancy or weight gain), not typically concerning unless new or severe. Distention is more urgent. Assuming striae require reporting risks diverting focus from serious findings, potentially delaying evaluation of critical abdominal conditions needing immediate medical attention.
Choice C reason: Borborygmus (bowel sounds) is a normal finding, indicating active digestion, unless absent or hyperactive. Distention is abnormal and urgent. Assuming borborygmus requires reporting risks misprioritizing normal findings, neglecting serious issues like distention, critical for timely diagnosis and management of abdominal pathology.
Choice D reason: Abdominal symmetry is expected in healthy assessments, unlike distention, which signals pathology. Assuming symmetry is unexpected risks overlooking abnormal findings, diverting focus from urgent issues like obstruction or ascites. Reporting distention ensures prompt evaluation, critical for addressing underlying causes and preventing complications in patients.
Correct Answer is B
Explanation
Choice A reason: Joint deformity is an unexpected musculoskeletal finding, indicating conditions like arthritis or trauma, requiring intervention. Symmetrical movement is normal. Assuming deformity is expected risks neglecting serious issues, delaying treatments like physical therapy or surgery, critical for restoring function and preventing disability in affected patients.
Choice B reason: Symmetrical degrees of movement are expected in musculoskeletal assessments, indicating normal joint function and muscle strength. Asymmetry, deformity, or limited movement are abnormal. Recognizing this ensures focus on true abnormalities, guiding accurate diagnosis and interventions for musculoskeletal issues, critical for maintaining mobility and function in patients.
Choice C reason: Limited ability to complete maneuvers is an unexpected finding, suggesting joint stiffness, pain, or weakness, possibly from arthritis or injury. Symmetrical movement is normal. Assuming this is expected risks missing treatable conditions, delaying interventions like therapy or medication, critical for improving musculoskeletal function and patient quality of life.
Choice D reason: Differences in movement between right and left sides are unexpected, indicating asymmetry from conditions like stroke or injury. Symmetrical movement is normal. Assuming asymmetry is expected risks overlooking neurological or musculoskeletal issues, delaying diagnosis and rehabilitation, critical for restoring balanced function in patients with movement disparities.
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