Anatomy & Physiology I/II · practice question

A 73-year-old client on a telemetry unit is being evaluated for nursing care related to musculoskeletal structure and mobility. Assessment data include vital signs change from earlier: blood pressure 94/60 mm Hg and heart rate 112/min. Which finding requires the nurse to intervene immediately?

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A stable, long-standing finding that matches the expected care plan.The new finding that vital signs change from earlier: blood pressure 94/60 mm Hg and heart rate 112/min.A comfort request with unchanged vital signs and no new symptoms.Routine data unchanged from the prior assessment.

Answer and explanation

Correct answer

B. The new finding that vital signs change from earlier: blood pressure 94/60 mm Hg and heart rate 112/min.

Why

Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.

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A 73-year-old client on a telemetry unit is being evaluated for nursing care related to musculoskeletal structure and mobility. Assessment data include vital signs change from earlier: blood pressure 94/60 mm Hg and heart rate 112/min. Which finding requires the nurse to intervene immediately?

Correct answer

Why

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