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.
The blood pressure reading of 160/100 indicates hypertension, which is considered outside the normal range. This significantly elevated blood pressure is the only abnormal vital sign among the listed options.
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, this option does not reflect an abnormal vital sign.
B) pulse
A pulse rate of 88 beats per minute is also within the normal range for adults, which is generally between 60 and 100 beats per minute. Thus, this choice is not indicative of an abnormality.
C) respirations
The respiration rate of 20 breaths per minute is at the upper limit of the normal range for adults, which is typically between 12 and 20 breaths per minute. While it is on the higher side, it does not constitute an abnormal vital sign.
D) blood pressure
The blood pressure reading of 160/100 is considered hypertensive, which is significant and indicative of a health concern. This reading is clearly outside the normal range, making it the only abnormal vital sign among the choices provided.
Conclusion
The blood pressure reading is the only vital sign that deviates from the normal parameters, identifying it as the abnormal vital sign. In contrast, the temperature, pulse, and respiration rates all fall within acceptable limits, reinforcing the conclusion that blood pressure is the primary concern in this scenario.