During a physical assessment, which finding would require immediate nursing intervention?

Prepare for the ATI Fundamentals II Exam using flashcards and multiple choice questions. Each question is designed to guide and explain, helping you master essential concepts. Get set to ace your test!

Cool and clammy skin is a critical finding that requires immediate nursing intervention. This symptom often suggests inadequate perfusion or could be indicative of a serious underlying issue, such as shock or hypoglycemia. The skin's temperature and moisture can provide crucial insights into a patient's circulatory status and overall health. When the skin is cool and clammy, it may signal that the body is diverting blood away from the skin to maintain perfusion to vital organs, which can be a sign of distress.

In contrast, a patient reporting a mild headache might not need immediate intervention, as headaches can be common and often self-resolving. A heart rate of 88 beats per minute falls within a generally acceptable range for adults, indicating no immediate cardiovascular concern. Lastly, a normal blood pressure reading suggests that the patient's hemodynamics are stable at that moment, and thus does not warrant urgent action.

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