California Certified Nursing Assistant (CNA) Practice Exam

Which observation would require immediate reporting to the nursing staff?

1. A client refusing to take medication

2. Severe changes in a client’s vital signs

3. A minor skin rash developing

4. A client expressing frustration

The correct answer is: Severe changes in a client’s vital signs

Severe changes in a client’s vital signs are critical indicators of the individual's current health status and can signify underlying issues that may require urgent medical intervention. Vital signs, which include temperature, pulse, respiration, and blood pressure, provide essential information about the body's basic functions. When there are severe deviations from normal ranges, such as significantly elevated blood pressure, extreme fluctuations in heart rate, or marked changes in respiratory rate, these can be indicative of serious health concerns, such as heart failure, infection, or respiratory distress. Such changes may indicate that the client is in a potentially life-threatening condition that needs prompt attention from the nursing staff. In contrast, while a client refusing medication, developing a minor skin rash, or expressing frustration may warrant attention and follow-up, they do not typically represent immediate threats to the client’s health and safety that would necessitate urgent reporting to nursing staff.