75.6k views
4 votes
One of the unlicensed assistive personnel (UAP) reports the following vital signs (VS) obtained from a patient with a suspected brain injury: temperature = 101.6° F orally, heart rate = 58, R = 14, and blood pressure = 162/48. What is the nurse's priority response?

Ask the UAP to repeat the blood pressure.
Compare the current VS to baseline VS recorded.
Validate the VS by repeating the VS measurements.
Administer prescribed acetaminophen (Tylenol) for fever.

User Joan Rieu
by
8.1k points

1 Answer

5 votes

Final answer:

The nurse's priority should be to immediately validate the vital signs, especially the abnormal measurements like the wide pulse pressure, by repeating the measurements themselves, because accuracy is critical in managing a patient with a suspected brain injury.

Step-by-step explanation:

The nurse's priority response to the vital signs reported for a patient with a suspected brain injury should be to validate the VS by repeating the VS measurements. The vital signs showing a high body temperature of 101.6° F, a low heart rate of 58 (below the normal 60-100 beats per minute), a normal respiratory rate of 14 breaths per minute (within the standard 12-18 range), and an abnormal blood pressure of 162/48 (indicating a wide pulse pressure, which may be a concern in the context of brain injury), suggest that immediate verification is critical. The discrepancy particularly in the blood pressure, which has a very low diastolic value, could be a sign of a serious condition such as a brain injury response or shock and should be confirmed before proceeding with treatment.

Once vital signs have been validated, comparing them to the patient's baseline readings would be important for context. However, as the patient has a suspected brain injury, potentially abnormal vital signs may indicate changes that require immediate medical intervention. Hence, verification should take precedence over comparison in this context.

Administering an antipyretic such as acetaminophen for fever without verifying other critical vital signs could mask symptoms that are essential for diagnosis and immediate treatment. Therefore, medication should only be considered after accurate assessment and under medical guidance

User Lnshi
by
9.0k points