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?
Temperature
Respirations
Blood pressure
Heart rate
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 ["A","B"]
Explanation
A. Bronchovesicular sounds are normal lung sounds that are typically heard over the mainstem bronchi and are expected during auscultation.
B. Bronchial sounds are also normal and are typically heard over the trachea; they are expected lung sounds.
C. Dullness is not a lung sound but rather a descriptor of percussion notes, typically indicating fluid or solid mass in the lungs.
D. Flatness is also not a normal lung sound but refers to a percussion note that can suggest the presence of fluid or a solid mass.
Correct Answer is ["B","D","E","F"]
Explanation
A. Hypoactive oil and sweat glands: Pregnancy typically causes increased activity in oil and sweat glands, not decreased.
B. Increased skin pigmentation: Increased pigmentation is common during pregnancy, often affecting areas like the areolas and abdomen.
C. Persistent migraine headaches: While some women may experience headaches in pregnancy, they are not an expected or typical finding and may require further assessment.
D. Facial edema: Mild facial edema can occur as pregnancy progresses, especially due to increased blood volume and fluid retention.
E. Melasma: Melasma, or "mask of pregnancy," is a common finding characterized by dark patches on the face due to hormonal changes.
F. Linea nigra: Linea nigra is a dark line that often appears on the abdomen during pregnancy as a result of hormonal changes.