A patient reports severe abdominal pain. When assessing the vital signs, the nurse would not be surprised to find what assessments?

Correct Answer: A

Rationale: Pain stimulates the sympathetic nervous system, often increasing pulse rate as the body responds to stress, a common finding in acute abdominal pain. A decrease in body temperature isnt typical, as pain may elevate temperature if inflammation is present. A decrease in blood pressure could occur in shock but isnt a primary pain response; pain often increases blood pressure initially. An increase in respiratory depth (D replaced with E) and rate (E) may occur, but the correct answer focuses on A. Pain typically accelerates pulse and respiratory rate while potentially decreasing depth, not increasing it. Choice A is correct as it consistently aligns with physiological responses to severe pain, supported by clinical observations of tachycardia in painful conditions like appendicitis or perforation.

Correct Answer: B

Rationale: Pulse pressure is systolic minus diastolic: 140 - 60 = 80 . 60 is diastolic. 140 is systolic. 200 is unrelated. Choice B is correct, reflecting arterial pressure dynamics, a key nursing calculation.

Correct Answer: B

Rationale: Hypothermia is a core temperature below 95°F (35°C), but 96.8°F (36°C) is a practical threshold for early detection . An increase over 96.8°F suggests normothermia or fever. Cyanosis is a symptom, not hypothermia. ‘None' is incorrect. Choice B is correct, aligning with nursing definitions (e.g., CDC) where subnormal temperature signals risk, guiding interventions like warming to prevent complications.

Correct Answer: C

Rationale: Respiratory rate is breaths per minute , typically 12-20 for adults, counting full cycles. Inhaling or exhaling alone isn't standard. Oxygen saturation is a separate metric. Choice C is correct, per nursing definitions, a vital sign tracked to assess breathing adequacy and detect respiratory issues.

Correct Answer: D

Rationale: Assessing temperature changes requires RN judgment, not delegable. NAP can select routes/devices , measure , and note norms under direction. Choice D is correct, per RN scope (e.g., NCSBN) reserving assessment for licensed nurses.