Chapter 12: Vital Signs

A client asks the nurse if there are risk factors for hypertension. What is the most appropriate nursing response?

"Hypertension can be caused by many things, including anxiety and obesity."

A nurse is assessing a newborn at the health care facility when the mother of the child asks the nurse why the body temperature of her baby is unstable. Which response by the nurse would be most appropriate?

"It is because of the immature ability to regulate temperature in general."

A nurse educator is teaching a client about a healthy diet. What information would be included to reduce the risk of hypertension?

"Put away the salt shaker and eat low-salt foods."

The home care nurse notices that the client only has a glass thermometer. What is the best response by the nurse?

"Would you consider using a digital thermometer?"

Based upon circadian rhythms, when would the nurse note the highest temperature during a 24-hour period?

1700

When assessing an infant's axillary temperature, it will be:

1°F (0.5°C) lower than an oral temperature

A nurse is assessing the respiratory rate of a sleeping infant. What would the nurse document as a normal finding?

30 to 60 breaths per minute

A nurse is assessing the cardiac output of a client at the health care facility. What would the nurse identify as the average cardiac output in a resting person?

5.5 L/min

A nurse is obtaining vital signs from patients using the tympanic method for measuring temperature. Which client should the nurse avoid use o the tympanic method when obtaining a termperature reading?

A client that has an ear infection with pain

The nurse is preparing to measure a client's rectal temperature. Which supplies and equipment should the nurse have available before beginning the procedure? Select all that apply.

An electronic thermometer with a rectal probe Disposable probe cover Water-soluble lubricating gel

A client is taking medications to treat a heart dysrhythmia. Which site should be used to assess the pulse in this client?

Apical

The nurse is preparing to measure an adult's radial pulse using a Doppler device. Arrange the following steps of the procedure in the correct order.

Apply conducting gel to the site where the pulse will be auscultated. Place the Doppler probe tip in the gel. Adjust the volume of the device, as needed. Maneuver the tip of the Doppler probe over the area until the pulse is heard. Count the number of heartbeats for 1 full minute. Wipe the gel off of the client's skin.

A client has had a left-side mastectomy. How does this affect the blood pressure assessment

Assessment of blood pressure is impeded.

A nurse is reviewing the trends of a client's vital signs since the client's admission and has noted significant variations in the client's blood pressure readings over the course of each day. Which statement best describes the typical circadian rhythm of blood pressure?

Blood pressure is lowest after midnight and begins to rise in the early morning

While assessing vital signs of a client with a head injury and increased intracranial pressure (IICP), a nurse notes that the client's respiratory rate is 8 breaths/minute. How will the nurse interpret this finding?

Bradypnea is a response to IICP.

While assessing for orthostatic hypotension, the nurse follows which steps when taking the blood pressure? Select all that apply.

Check and record blood pressure taken while the client is in the bed. Assist client to standing position and wait 2 minutes before taking his blood pressure. Record measurements and report a drop of 25 mm Hg systolic and 10 mm Hg diastolic. Keep the blood pressure cuff attached the whole time.

Which client should not have a temperature assessed rectally

Client with diarrhea

The nurse is assessing the pulse amplitude for a client. Documentation by the nurse states, "Pulses are +1 in the lower left extremity". What amplitutde is the nurse assessing?

Diminished, weaker than expected

A nurse is caring for a client with orthostatic hypotension. What are symptoms of orthostatic hypotension? Select all that apply.

Dizziness Syncope Nausea Weakness

Which describes diastolic blood pressure?

During ventricular relaxation, blood pressure is due to elastic recoil of the vessels.

Which piece of equipment is no longer used for temperature measurement?

Glass mercury thermometers

The nurse is assessing a female client for orthostatic hypotension. As the nurse assists the client to a standing position, the client states, "I'm feeling really dizzy." What should the nurse do next?

Immediately assist the client back to bed.

The nurse is preparing to assess the peripheral pulse of an adult client. Which action is correct?

Lightly compress the client's radial artery using the first, second, and third fingers.

A nurse records a pulse rate of 170 beats/min on a client's flow chart. For which of the following age groups would this be considered a normal reading?

Newborn

A student is reading the medical record of an assigned client and notes the client has been afebrile for the past 12 hours. What does the term "afebrile" indicate?

Normal body temperature

A nurse is caring for a client who is ambulating for the first time after surgery. Upon standing, the client reports dizziness and faintness. The client's blood pressure is 90/50. What is the name for this condition?

Orthostatic hypotension

A nurse palpates the pulse of a client and documents the following: 6/6/12 pulse 85 and regular, +3, and equal in radial, popliteal, and dorsalis pedis. What does the number +3 represent?

Pulse amplitude

A nurse is assessing the pulse volume of a client with influenza. The nurse notes that the client has a thready pulse. Which of the following is a description of a thready pulse?

Pulse is felt with difficulty and disappears with slight pressure.

Which term indicates a potentially serious client condition?

Pyrexia

The arterial blood gases for a client in shock demonstrate increased carbon dioxide and decreased oxygen. What type of respirations would the nurse expect to assess based on these findings?

Rapid and deep

A nurse is taking a client's temperature and wants the most accurate measurement, based on core body temperature. What site should be used?

Rectal

A nurse must assess the blood pressure of a client who has intravenous catheters in both arms. As a result, the nurse will assess the client's blood pressure on the thigh. How will this assessment result differ from blood pressure that is measured on a client's arm?

Systolic blood pressure will be 10% to 20% higher than that obtained in the arms, but the diastolic blood pressure will be similar.

An 80-year-old client has a body temperature of 97°F (36°C). Which condition best accounts for this client's temperature reading?

Temperature drops with age.

The nurse has just received the beginning-of-shift report about assigned clients. Based on the following vital signs, which client should the nurse plan to assess first?

The 2-year-old client whose respiratory rate is 16 breaths/min

The nurse is obtaining vital signs for a client and assesses a heart rate of 124 beats per minute. What additional assessment information would be important to obtain that would explain the tachycardia?

The client has reports of pain of 8 on a scale of 0-10 The client just finished ambulating with physical therapy The client has a temperature of 101.8 degrees Fahrenheit

A client in a physician's office has a blood pressure (BP) reading of 150/92 mm Hg. What must be considered prior to this client being diagnosed as having hypertension?

The client must have at least two blood pressure readings that are elevated for the diagnosis.

The nurse is documenting the client's morning assessment. Which data indicate subjective data?

The client's pain level is a 4 on a scale of 0-10.

A nurse is assessing the blood pressure on an obese woman. What error might occur if the cuff used is too narrow?

The reading is erroneously high.

A nurse is assessing the blood pressure of a client using the Korotkoff sound technique. The nurse notes that the phase I sound disappears for 2 seconds. What should the nurse document on the progress record?

There is an auscultatory gap

Upon auscultation of a client's heart rate, the nurse notes the rate to have an irregular pattern of 72 beats/min. The nurse notifies the physician because the client is exhibiting signs of:

Upon auscultation of a client's heart rate, the nurse notes the rate to have an irregular pattern of 72 beats/min. The nurse notifies the physician because the client is exhibiting signs of:

The nurse is preparing to assess the client's vital signs. The client just had their morning coffee. What is the appropriate nursing intervention?

Wait 30 minutes, then assess the oral temperature.

Clients demonstrating apnea have what?

a temporary cessation of breathing

All of the following clients have a body temperature of 38°C (100.4°F). About which client would a nurse be most concerned?

an infant 2 months of age

A nurse who is on a night shift has checked on the status of each sleeping client and has observed that a client's breathing occasionally stops for several seconds before resuming spontaneously. The nurse should document the presence of:

apnea.

A nurse is assessing an apical pulse on a cardiac client. The client is taking digoxin. The nurse can anticipate that the digoxin will:

decrease the apical pulse.

Which is not a characteristic used to describe the pulse?

depth

A nurse needs to assess the temperature of a client with high fever. Which site will most closely reflect core body temperature of the client?

ear

Which condition will lead to an increase in cardiac output?

exercise

The temperature is 102°F (39°C) during a heat wave. The nurse can expect admissions to the emergency room to present with:

increased temperature

A nurse is caring for a client whose skin has become pinkish and warm to touch. The client shivers when the windows are opened. Which phase of fever is the client experiencing?

invasion phase

Which site for taking body temperature with a glass thermometer is contraindicated in clients who are unconscious?

oral

A nurse is taking a client's temperature and wants the most accurate measurement, based on core body temperature. What site should be used

rectal

What equipment is needed to take an apical pulse?

stethoscope

The nurse is taking the client's temperature. The nurse understands that the rectal route is one of the most reliable. Which client can safely handle the rectal route of taking temperature

the 65-year old male who just finished drinking coffee

A nurse is assessing the blood pressure of a team of healthy athletes at the heath care facility. Which observation can be made by the nurse and athletes by measuring the blood pressure?

the ability of the arteries to stretch

A pulse deficit is the difference between:

the apical pulse and the radial pulse rates.

The client's blood pressure has gradually decreased in the last 2 days. Which condition would cause this change?

the client who has had persistent diarrhea