Hesi RN Fundamentals of Nursing
Hesi RN Fundamentals of Nursing ( 44 Questions)
The nurse observes a decrease in a client's level of consciousness. Which vital sign should the nurse obtain first?
Blood pressure is not the first vital sign to obtain because it is not as sensitive to changes in the level of consciousness as respiratory rate. Blood pressure may be normal or elevated in some cases of decreased consciousness, such as stroke or head injury.
Temperature is not the first vital sign to obtain because it is not as relevant to the level of consciousness as respiratory rate. Temperature may be normal or slightly elevated in some cases of decreased consciousness, such as infection or dehydration.
Respiratory rate is the first vital sign to obtain because it reflects the adequacy of oxygenation and ventilation, which are essential for brain function. Respiratory rate may be increased, decreased, or irregular in cases of decreased consciousness, depending on the cause and severity.
Pulse rate is not the first vital sign to obtain because it is not as indicative of the level of consciousness as respiratory rate. Pulse rate may be normal, fast, or slow in cases of decreased consciousness, depending on the cause and compensatory mechanisms.
Choice A: Blood pressure is not the first vital sign to obtain because it is not as sensitive to changes in the level of consciousness as respiratory rate. Blood pressure may be normal or elevated in some cases of decreased consciousness, such as stroke or head injury.
Choice B: Temperature is not the first vital sign to obtain because it is not as relevant to the level of consciousness as respiratory rate. Temperature may be normal or slightly elevated in some cases of decreased consciousness, such as infection or dehydration.
Choice C: Respiratory rate is the first vital sign to obtain because it reflects the adequacy of oxygenation and ventilation, which are essential for brain function. Respiratory rate may be increased, decreased, or irregular in cases of decreased consciousness, depending on the cause and severity.
Choice D: Pulse rate is not the first vital sign to obtain because it is not as indicative of the level of consciousness as respiratory rate. Pulse rate may be normal, fast, or slow in cases of decreased consciousness, depending on the cause and compensatory mechanisms.