Question

A patient is admitted to the emergency department with a closed head injury. The patient is awake but lethargic, and the baseline vital signs include a blood pressure of 120/80 mm Hg, pulse of 78 beats/minute, and respirations of 20 breaths/minute. Two hours later the nurse assesses the patient. Which finding indicates deterioration in the patient's condition?

The patient does not remember what happened.
The patient is sleeping but awakens in response to painful stimuli.
Blood pressure is 110/80 mm Hg, pulse is 78 beats/minute, and respirations are 20 breaths/minute.
Blood pressure is 160/74 mm Hg, pulse is 53 beats/minute, and respirations are 10 breaths/minute.

Answer 1

The finding that indicates deterioration in the patient's condition is a blood pressure of 160/74 mm Hg, pulse of 53 beats/minute, and respirations of 10 breaths/minute. These values are outside the normal ranges and suggest a worsening of the patient's condition.

Step-by-step explanation:

The finding that indicates deterioration in the patient's condition is a blood pressure of 160/74 mm Hg, pulse of 53 beats/minute, and respirations of 10 breaths/minute.

A normal blood pressure ranges from 90/60 to 120/80 mm Hg, so a blood pressure of 160/74 mm Hg is significantly higher than normal.

A normal pulse rate ranges from 60-100 beats per minute, so a pulse of 53 beats/minute is lower than normal.

Similarly, a normal respiratory rate ranges from 12-18 breaths per minute, so respirations of 10 breaths/minute is lower than normal. These findings indicate that the patient's condition has deteriorated and requires immediate medical attention.