36. A client's vital signs are T 98.8, P 88, R 20, BP 160/100. The abnormal vital sign is
Answer: D
The abnormal vital sign is blood pressure.
In this case, the client's blood pressure reading of 160/100 is significantly elevated, indicating hypertension, while the other vital signs fall within normal ranges.
A) temperature
The temperature of 98.8°F is within the normal range for adults, which typically falls between 97°F and 99°F. Therefore, it does not indicate any abnormality.
B) pulse
A pulse rate of 88 beats per minute is considered normal for adults, which generally ranges from 60 to 100 beats per minute. This vital sign does not indicate any abnormal condition.
C) respirations
The respiratory rate of 20 breaths per minute is at the upper end of the normal range for adults, which is typically 12 to 20 breaths per minute. Thus, this vital sign does not signify an abnormality.
D) blood pressure
The blood pressure reading of 160/100 is classified as stage 2 hypertension, indicating a significant deviation from normal blood pressure levels, which should ideally be around 120/80 mmHg. This makes it the abnormal vital sign in this assessment.
Conclusion
The correct answer is blood pressure, as it is the only vital sign that indicates a serious health issue, specifically hypertension. All other vital signs provided are within normal limits, confirming that they do not present any concerns in this context.