The nurse is caring for a client who is admitted to the hospital with a diagnosis of pneumonia. The client is on a monitor, and vital signs are recorded from the monitor in order to leave the client undisturbed during the night
The nurse observes that blood pressure, heart rate, and respirations are below baseline for this client. Based on this data, which conclusion by the nurse regarding the changes in vital signs is the most appropriate?
A) The client is about to have a cardiac arrest.
B) The client is in stage IV of NREM sleep.
C) The client's metabolic rate has increased.
D) The client is in stage II of NREM sleep.
Answer: B
During stage IV sleep, the client is relaxed, and vital signs decrease from baseline by 20% to 30%. Stage II sleep is characterized by light sleeping with vital signs decreasing slightly. The client's metabolic rate is decreased in stage IV. A decrease in vital signs is normal during stage IV sleep, and the client is not necessarily at risk for cardiac arrest.
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