During the evening assessment of a febrile client admitted to the nursing unit with abdominal pain, the nurse assesses a lower than normal blood pressure and a rapid pulse. These findings suggest to the nurse that the client may be experiencing:

Question

1. anxiety.
2. an abdominal infection.
3. a medication reaction.
4. a diurnal variation

Answer 1

2
Rationale 1: The physiologic response to anxiety is increased heart rate and increased blood pressure.
Rationale 2: The lowered blood pressure and increased heart rate in a febrile client with abdominal pain is suggestive of infection. Fever causes vasodilation, which in turn causes an increase in heart rate.
Rationale 3: There is no information to suggest that the client is experiencing a reaction to medication.
Rationale 4: Diurnal variation of blood pressure is exhibited by lower morning blood pressure that increases throughout the day.