Progressive Care Nursing Certification (PCCN) Practice Exam

Which vital sign finding would most likely suggest the need for immediate intervention in a patient with severe headache?

1. Heart rate of 80 bpm

2. BP of 120/80 mm Hg

3. BP of 280/140 mm Hg

4. Respiratory rate of 18 breaths/min

The correct answer is: BP of 280/140 mm Hg

A blood pressure reading of 280/140 mm Hg indicates severe hypertension, which can be a critical situation requiring immediate intervention. This level of high blood pressure could suggest a hypertensive crisis, which may lead to complications such as end-organ damage or hemorrhagic stroke, particularly in someone experiencing a severe headache. Severe headaches can be associated with conditions such as hypertensive encephalopathy, aneurysms, or intracranial hemorrhage, and such an elevated blood pressure can exacerbate these risks. Therefore, rapid assessment and intervention, including medication to lower blood pressure and further evaluation, are essential to prevent potential life-threatening consequences. In contrast, a heart rate of 80 bpm is within normal limits and does not raise immediate concern. A blood pressure of 120/80 mm Hg is also considered normal and does not necessitate intervention. Similarly, a respiratory rate of 18 breaths per minute falls within the normal range for adults, suggesting stable respiratory function. Hence, the significantly elevated blood pressure in the correct response is the most critical finding that indicates the need for immediate action.