Certified Medical-Surgical Registered Nurse Practice Exam

While performing a head-to-toe assessment, which observation should alert the nurse for further evaluation?

1. Heart rate of 80 beats per minute.

2. Persistent headache lasting more than two days.

3. Blood pressure of 120/80 mmHg.

4. Body temperature of 98.6°F.

The correct answer is: Persistent headache lasting more than two days.

A persistent headache lasting more than two days is a significant finding that warrants further evaluation. While headaches can be common and often benign, a headache that is prolonged and does not resolve within a typical timeframe may indicate an underlying issue. This could include factors such as increased intracranial pressure, neurological conditions, or other systemic problems. In a head-to-toe assessment, a change in the patient's usual state is always a red flag. The duration and persistence of the headache raise concern, particularly if it is accompanied by other symptoms such as visual disturbances, change in consciousness, or other neurological deficits. These factors necessitate a deeper investigation to rule out serious conditions that may need immediate intervention. On the other hand, the other observations such as heart rate, blood pressure, and body temperature all fall within acceptable normal ranges, indicating stable vital signs, which would not typically require immediate further evaluation. This highlights the importance of recognizing deviations in a patient’s typical clinical presentation, such as a prolonged headache, as critical indicators for potential issues.