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An assistive personnel (AP) reports a client's vital signs as tympanic temperature 37.1° C (98.8° F), pulse 42/min, respiratory rate 14/min, and BP 98/77 mm Hg. Which vital sign should the nurse re-measure?

A.

Temperature

B.

Respirations

C.

Blood pressure

D.

Heart rate

Answer and Explanation

The Correct Answer is D

A. The tympanic temperature of 37.1° C (98.8° F) is within normal limits and does not require re-measurement.  

 

B. The respiratory rate of 14/min is also within the normal range (12-20 breaths per minute).  

 

C. The blood pressure of 98/77 mm Hg is not alarmingly low and does not require immediate re-measurement.  

 

D. A pulse rate of 42/min indicates bradycardia (normal resting heart rate is typically between


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Correct Answer is ["D","F"]

Explanation

A. This statement indicates complete paralysis of both sides, which does not apply to hemiparesis, where one side is affected.


B. While this could describe some patients, it does not accurately represent "complete" right-sided hemiparesis.


C. This option is a repeat and also does not accurately reflect complete right-sided hemiparesis.


D. Weakness on the right side of the face and tongue is consistent with right-sided hemiparesis, as the stroke may affect motor control in those areas.


E. This describes a client who is less severely affected and may not apply to someone with complete right-sided hemiparesis.


F. Weakness on the right side of the body is a direct characteristic of right-sided hemiparesis.

Correct Answer is A

Explanation

A. Ventricular tachycardia: Ventricular tachycardia (VT) is identified by a regular, fast rhythm with wide QRS complexes, typically without visible P waves. This rhythm often appears as consecutive, large, uniform waves, which is consistent with what is seen in the diagram.

B. Asystole: Asystole is characterized by a flat line, indicating no electrical activity, which is not present in this strip.

C. Normal sinus rhythm: Normal sinus rhythm would show identifiable P waves, a normal QRS complex, and a regular rate, which are not observed here.

D. Ventricular fibrillation: Ventricular fibrillation appears as chaotic, irregular waveforms with no clear QRS complexes or organization, which does not match the rhythm shown.

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