The nurse is completing an assessment on a patient who was just ...

[silviawilliams41]

The nurse is completing an assessment on a patient who was just admitted from the emergency department. Which assessment findings would require immediate attention? Select all that apply.
 
  a. Temperature: 38.6  C
  b. Systolic blood pressure: 150 mm Hg
  c. Respiratory rate: 22 breaths per minute
  d. Heart rate: 130 beats per minute
  e. Oxygen saturation: 95
  f.
  Sudden restlessness

Question 2

When assessing the neurologic system of a hospitalized patient during morning rounds, the nurse should include which of these during the assessment?
 
  a. Blood pressure
  b. Patient's rating of pain on a scale of 1 to 10
  c. Patient's ability to communicate
  d. Patient's personal hygiene level

[ryhom]

Answer to Question 1

ANS: A, D, F
The following examination findings require immediate attention:
High or low temperature: (36.1  C or 37.8  C)
High or low blood pressure: (systolic pressure 90 mm Hg or 160 mm Hg)
High or low number of respirations: (12 or 28 breaths per minute)
High or low heart rate: (60 or 90 beats per minute)
Oxygen saturation: 92
Sudden restlessness or anxiety, altered level of consciousness, confusion, or difficulty in arousing

Answer to Question 2

ANS: C
Assessment of a patient's ability to communicate is part of the neurologic assessment. Blood pressure and pain rating are measurements, and personal hygiene is assessed under general appearance.