Chapter 5: Vital Signs and General Survey

A nurse notes that the pulse rate of a client is less than 60 beats per minute. Which question is appropriate for the nurse to ask the client in regards to this finding?

"Have you been sitting for a long time?"

A nurse is assessing the general status and vital signs of a client. Which of the following are subjective findings, which the nurse obtained from the client? Select all that apply

-Date and location of the clients last blood pressure check -Onset and character of the clients chest pain -A list of all of the client's current medications

A nurse has an order to obtain orthostatic blood pressure readings on a client admitted with dehydration. The sitting blood pressure is 140/75 mm Hg. Which blood pressure reading with the client standing should the nurse recognize as orthostatic hypotension?

120/55 mm Hg

A nurse has assessed the blood pressure of a recently admitted patient and obtained a reading of 128/78 mm Hg. What is this patient's pulse pressure?

50 mm Hg

Due to a change in the client's level of consciousness, a nurse is now assessing a client's temperature by the axillary route. Previously, the client had an oral temperature of 98.4ºF. Which finding would the nurse interpret as corresponding most closely to the client's previous temperature?

97.4ºF

The nurse obtains a client's blood pressure when standing and compares it to the measurement obtained while the client was sitting. The client's blood pressure when sitting was 122/72 mmHg. Which finding would suggest to the nurse that the client is experiencing orthostatic hypotension?

98/52 mmHg

What population is at greatest risk for hypertension?

African American

What are various measurements of the human body, including height and weight, called?

Anthropometric

Which abnormal skin color should a nurse anticipate assessing on a dark-skinned client?

Ashen gray

The nurse palpates a client's pulse and notes that the rate is 61 beats per minute, with an amplitude that is weak and thready. How should the nurse respond to this assessment finding?

Assess the client's pulse at the carotid site

The nurse is auscultating a client's blood pressure, and identifies which of the following as the portion of the blood pressure cycle reflecting the break in sounds occurring between the first and second sounds?

Auscultatory gap

A nurse obtains a pulse rate on an adult client of 56 beats per minute. What is the correct term that the nurse should use to document this finding?

Bradycardia

Which of the following would be most appropriate for the nurse to do to determine stroke volume?

Calculate the difference between the diastolic and systolic pressures.

The information gathered during a general survey provides the nurse primarily with which of the following?

Clues about the overall health of the client

The nurse is admitting a client to surgical daycare and is assessing the client's vital signs. When obtaining the client's oral temperature, where should the nurse insert the thermometer?

Deep in the posterior sublingual pocket

The nurse is performing vital signs during the routine assessment of an adult client who twisted his ankle during a mini-marathon. The client's pulse is 52 bpm. The nurse retakes the pulse; the finding is the same. The client tells the nurse that he has been training for 6 months for this mini-marathon. What should the nurse do in regard to this reading?

Document the finding

Which assessment would be most important for the nurse to complete to ensure safety with a client receiving antihypertensive agents?

Evaluating orthostatic hypotension

The nurse is assessing a client's pain. Which of the following would lead the nurse to suspect that the client is experiencing pain?

Facial grimacing, leaning forward

A nurse documents a client's radial pulse as 2+, indicated which of the following?

It occludes with moderate pressure

A nurse obtains the blood pressure in a client who is lying down. Which of the following would the nurse expect?

It will be slightly lower than standing readings

A nurse observes that a young man's arm span appears to be greater than his height. Which condition should the nurse suspect in this client?

Marfan's syndrome

Two nurses collaborate in assessing an apical-radial pulse on a patient. The pulse deficit is 16 beats/min. What does this indicate?

Not all of the heartbeats are reaching the periphery

A nurse needs to measure the blood pressure of a client who has just undergone a bilateral mastectomy. How should the nurse measure the blood pressure?

Over the client's thigh

When assessing a client's respirations, what is most important to include in the documentation?

Presence of dyspnea

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

Reading is erroneously high.

The nurse is reviewing the following vital signs of a client who is lying in bed. Which of the following would the nurse identify as being abnormal?

Respirations 28 breaths/minute

A nurse measures a client's blood pressure at 174/102 mm Hg. The nurse recognizes this as what classification of blood pressure measurement?

Stage 2 hypertension

A patient arrives in the emergency department in diabetic ketoacidosis. What assessment finding would the nurse expect in this patient?

Sweet-smelling breath

A nurse is preparing to assess a client's vital signs. In which order should the nurse assess them?

Temperature, pulse, respiration, and blood pressure

In which order should a nurse assess a client's vital signs?

Temperature, pulse, respiration, and blood pressure

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

The ability of the arteries to stretch

A nurse is assessing the blood pressure of a client using the Korotkoff's sounds 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

The nurse recognizes that assessment of core body temperature is quick, noninvasive, and safe using which method?

Tympanic

The nurse is conducting a general survey of a patient new to the clinic. In what part of the survey would the nurse assess the hair distribution on the patient's body?

When assessing the skin

The nurse begins a client assessment by conducting a general survey that focuses on objective observations. What is the primary purpose for collecting this sort of information first?

assists the nurse in formulating appropriate subjective questioning

A client's blood pressure is affected by

cardiac output, distensibility of the arteries, blood volume, blood velocity and viscosity

Which of the following is an average normal temperature in Centigrade for a healthy adult?

oral: 37.0°C

The nurse is going to take a blood pressure on a patient who has had a previous left mastectomy with lymph node dissection. What would be an appropriate action by the nurse?

take the blood pressure in the right arm

The nurse is assessing an elderly postsurgical client in the home. To begin the physical examination, the nurse should first assess the client's

vital signs