Chapter 8: Assessing General Health Status and Vital Signs PrepU

Which general survey questions will provide the nurse information regarding the client's personal makeup? Select all that apply. a. "What ethnic culture do you identify with?" b. "Have you parented any children?" c. "What role does regular exercise play in your life?" d. "Do you experience any traumatic physical injuries as a child?" e. "How would you describe your typical mood?"

a. "What ethnic culture do you identify with?" c. "What role does regular exercise play in your life?" d. "Do you experience any traumatic physical injuries as a child?" e. "How would you describe your typical mood?" Many factors contribute to the client's makeup-genetic composition, early illnesses, socioeconomic status, culture, gender identity and expression, nutrition, degree of fitness, mood state, geographic location, and age cohort. The number of children one parented is a detailed question that is not associated with the general survey.

Before assessing vital signs, the nurse knows that it is important to assess what? a. Any medications the client is currently taking b. The client's height and weight c. The client's mental status d. A complete family history

a. Any medications the client is currently taking Prior to assessing vital signs, it is important to assess any medications the client is currently taking because medications can affect a client's vital signs. It is not necessary to know the client's height and weight, mental status, or a complete family history before assessing vital signs because these things do not affect a client's vital signs.

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 a. Date and location of the clients last blood pressure check b. Respiratory rate c. Core body temperature d. Onset and character of the clients chest pain e. Blood pressure f. A list of all of the client's current medications

a. Date and location of the clients last blood pressure check d. Onset and character of the clients chest pain f. A list of all of the client's current medications Subjective findings, which are those the client must report to the nurse, include date and location of the clients last blood pressure check, the onset and character of the clients chest pain, and a list of all of the clients current medications. Objective findings, which are obtained by the nurses direct observation or assessment, include respiratory rate, core body temperature, and blood pressure.

Body temperature is not impacted by which of the following factors? a. Diet b. Diurnal cycle c. Physical activity d. Age

a. Diet Body temperature varies with diurnal cycle, physical activity, age, gender, and state of health. It also normally fluctuates with activity and time of day. Diet does not affect a client's body temperature, though if a client has consumed hot or cold food or beverages before having an oral temperature taken, the reading may be impacted. To ensure accuracy, the nurse should wait 15-30 minutes to take temperature after the client has had anything hot or cold to eat or drink, has smoked, or has chewed gum.

An older adult client with COPD has come to the clinic for a routine follow-up visit. The nurse escorts the client to an examination room and measures vital signs. The nurse would expect the client's vital signs to be what? a. Higher than normal b. Lower than normal c. Within normal limits d. The nurse would not routinely take this client's vital signs

a. Higher than normal Many variables can lead to increased vital signs, including pain, stress, anxiety, activity, and chronic disease processes. It is imperative that nurses measure vital signs correctly and accurately, understand the data, and communicate the findings appropriately. COPD is often a result of smoking and likely result in an increase in vital signs. The client's vital signs would be assessed at each clinic visit.

The nurse explains to the client that smoking has what effect on the body? Select all that apply. a. Hypertension b. Vasoconstriction c. Peripheral vascular disease d. Vasodilation e. Hypotension

a. Hypertension b. Vasoconstriction c. Peripheral vascular disease Smoking can cause vasoconstriction, hypertension and peripheral vascular disease, not vasodilation and hypotension.

The client is exercising. The nurse understands that exercise has what effect on the body? Select all that apply. a. Increased heart rate b. Decreased cardiac output c. Increased blood pressure d. Increased cardiac output e. Increased peripheral vascular resistance

a. Increased heart rate c. Increased blood pressure d. Increased cardiac output During exercise, the blood pressure, heart rate and cardiac output increase. Peripheral vascular resistance is related to circulatory disorders.

Upon assessing a client who is hemorrhaging, the nurse is most likely to assess which compensatory change in vital signs? a. Increased pulse rate b. Decreased pulse rate c. Increased temperature d. Decreased temperature

a. Increased pulse rate When the stroke volume decreases, such as when blood volume is decreased because of hemorrhage, the heart rate increases to try to maintain the same cardiac output.

A nurse obtains a client's blood pressure (BP) on admission in both arms: right arm BP is 130/75 mm Hg and left arm BP is 140/80 mm Hg. Which arm should the nurse use for subsequent blood pressure reading? a. Left arm b. Right arm c. Dominant arm d. Both arms

a. Left arm Blood pressure should be taken in the dominant arm first (right arm for most people). When assessing for the first time, BP should be measured in both arms. Subsequent readings should be taken in the arm with the highest measurement.

A nurse is filling out an incident report after an older adult client fell while attempting to transfer from her bed to a commode. Which of the following health problems should the nurse consider when client falls occur? a. Orthostatic hypotension b. Dyspnea c. Primary hypertension d. Secondary hypertension

a. Orthostatic hypotension Orthostatic hypotension is associated with weakness or fainting when one rises to an erect position. Hypertension and dyspnea do not typically result in loss of balance and/or consciousness.

Assessment of the pulse amplitude is accomplished by which of the following? a. Palpating the flow of blood through an artery b. Auscultating the area of the left ventricle c. Palpating the area of the left ventricle d. Auscultating the flow of blood through an artery

a. Palpating the flow of blood through an artery The pulse amplitude describes the quality of the pulse in terms of its fullness and reflects the strength of left ventricular contraction. It is assessed by the feel of the blood flowing through an artery.

The nurse is taking routine vital signs toward the end of shift. A client's BP reads 204/148. The client's baseline BP has been in the 130's systolic. What should the nurse do first? a. Retake the blood pressure b. Notify the physician immediately c. Give PRN blood pressure medications d. Document the findings

a. Retake the blood pressure When encountering an abnormal value, obtain the vital sign(s) again to assess accuracy. It would be inappropriate to notify the physician immediately, give PRN blood pressure medications, or document the findings before rechecking the reading.

The nurse is assessing an elderly client's blood pressure and finds it to be high. Which of the following characteristics should the nurse suspect to find in respect to this client's arteries? a. Rigid b. Resilient c. Straight d. Springy

a. Rigid The older clients artery may feel more rigid, hard, and bent. More rigid, arteriosclerotic arteries account for higher systolic blood pressure in older adults. Normal arteries should feel resilient, straight, and springy.

A student nurse assesses a blood pressure on an adult and finds it to be 140/86. What term is used for the top number (140)? a. Systolic pressure b. Diastolic pressure c. Pulse pressure d. Hypotension

a. Systolic pressure Maximum blood pressure is exerted on the walls of the arteries when the left ventricle pushes blood through the aortic valve into the aorta at the beginning of systole. The higher pressure (here, 140) is the systolic pressure.

Upon entering an adult client's room to begin a shift assessment, the nurse should call the rapid response team based on which assessment finding? a. Systolic pressure 180 mm Hg. b. Apical pulse 70 beats/minute. c. Respirations 12 breaths/minute. d. Oxygen saturation 95% on room air.

a. Systolic pressure 180 mm Hg. The nurse may call a rapid response team if the client displays the following: respirations less than 10 breaths/min; oxygen saturation less than 92%; pulse less than 55 beats/min or greater than 120 beats/min; systolic blood pressure less than 100 or greater than 170 mm Hg.

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? a. The ability of the arteries to stretch b. The thickness of the circulating blood c. The oxygen levels in the blood d. The volume of air entering the lungs

a. The ability of the arteries to stretch Measuring the blood pressure helps to assess the efficiency of the client's circulatory system. Blood pressure measurements reflect the ability of the arteries to stretch, the volume of circulating blood, and the amount of resistance the heart must overcome when it pumps blood. Measuring the blood pressure does not help in assessing the thickness of blood, oxygen level in the blood, or the volume of air entering the lungs.

A client has an oral temperature of 37.2 °C (99 °F). The nurse interviews the client. Which of the following pieces of interview data could be an influence on this high body temperature? a. The client has just run 4.82 km (3 miles) outside before coming to the interview. b. The client drinks eight glasses of water a day. c. The client has a history of hypothyroidism. d. The client reports having a toe infection treated with antibiotics 3 months ago.

a. The client has just run 4.82 km (3 miles) outside before coming to the interview. Several factors may cause normal variations in the core body temperature. Strenuous exercise can raise temperature.

During a general survey, the nurse asks if the client is feeling cold. What did the nurse most likely observe in the client? a. The client is wearing clothing that is inconsistent with warm weather. b. The client is bouncing both legs up and down while seated. c. The client has an oral temperature of 37°C (98.6°F) d. The client's lips are bluish in color

a. The client is wearing clothing that is inconsistent with warm weather. The question "Are you feeling cold?" would be applicable for the client who is wearing clothing that is inconsistent with warm weather. The question "Are you feeling cold?" would not be appropriate for the client who is bouncing both legs up and down while seated. This could indicate anxiety. An oral temperature of 37°C (98.6°F) is within normal limits while the bluish color of the lips is associated with cyanosis, a respiratory issue.

A nurse assesses a female client's core body temperature and finds that she has a slightly elevated temperature. Which of the following factors could explain this finding? Select all that apply. a. The client just finished exercising. b. The client is ovulating. c. The client is stressed. d. The client is hypoglycemic. e. The client has hypothyroidism. f. The client is starving.

a. The client just finished exercising. b. The client is ovulating. c. The client is stressed. Several factors may cause normal variations in the core body temperature. Strenuous exercise, stress, and ovulation can raise temperature. Body temperature is lowest early in the morning (4:00 to 6:00AM) and highest late in the evening (8:00PM to midnight). Hypothermia (lower than 36.5°C or 96.0°F) may be seen in prolonged exposure to the cold, hypoglycemia, hypothyroidism, or starvation. Hyperthermia (higher than 38.0°C or 100°F) may be seen in viral or bacterial infections; malignancies; trauma; and various blood, endocrine, and immune disorders.

The nurse is assessing a new client's blood pressure using a manual sphygmomanometer. Which of the following sounds constitutes the client's systolic blood pressure? a. The first appearance of faint but distinctive tapping sounds b. The last sound before there is complete and continuous silence c. The first sound that is audible after the auscultatory gap d. The transition from tapping sounds to muffled sounds

a. The first appearance of faint but distinctive tapping sounds The systolic blood pressure reading occurs during phase I, which is characterized by the appearance of faint but clear tapping sounds that gradually increase in intensity.

A client comes to the cardiovascular intensive care unit (CVICU) directly after a three-vessel coronary artery bypass graft (CABG). The client's orders state "maintain systolic blood pressure greater than 90 but less than 120." How does this order affect the monitoring of the client's blood pressure? a. The nurse will assess blood pressure more frequently to ensure that it does not go beyond the ordered limits b. Monitoring blood pressure once every hour is sufficient for this client c. Monitoring blood pressure every 4 hours is sufficient for this client d. The nurse can delegate monitoring of the client's blood pressure to the client care assistant

a. The nurse will assess blood pressure more frequently to ensure that it does not go beyond the ordered limits Vital signs reflect health status, cardiopulmonary function, and overall body function. They are called vital signs because of their importance as indicators of physiological state and response to physical, environmental, and psychological stressors. Changes in vital signs often indicate changes in health. Assessment of vital signs helps nurses to establish a baseline, monitor a client's condition, evaluate responses to treatment, identify problems, and monitor risks for alterations in health. It would not be appropriate to monitor this client's BP every hour or every 4 hours or to delegate the taking of this client's BP to a client care assistant.

The nurse recognizes that assessment of core body temperature is quick, noninvasive, and safe using which method? a. Tympanic b. Oral c. Rectal d. Axillary

a. Tympanic The tympanic temperature is a good device for measuring core body temperature because it measures temperature quickly and safely. The tympanic membrane is supplied by a tributary of the artery (internal carotid) that supplies the hypothalamus (the body's thermoregulatory center). Oral is the most commonly used because it is the easiest to obtain. Axillary temperature is usually about 0.5°F to 1.0° F below the oral temperature. Rectal readings are often 0.4°F to 0.5°F higher than the oral temperature.

Students are touring the hospital before starting their clinical rotations. The instructor points out that the type of thermometer used in this facility is noninvasive, safe, efficient, and quick. What type of thermometer is the instructor describing? a. Tympanic b. Rectal c. Oral d. Axillary

a. Tympanic Tympanic thermometers use infrared sensors to detect the heat that the tympanic membrane produces. The tympanic membrane thermometer is noninvasive, safe, efficient, and quick. Because the reading is so quick (2 to 3 seconds), it is commonly used in emergency departments and hospitals.

The nurse is assessing a client's respiratory rate. Which of the following should the nurse do to ensure accuracy of this assessment? a. Watch chest movement before removing the stethoscope after counting the apical beat b. Ask the client to breathe normally c. Observe the client's chest movement before calling the client back to the examination room d. Perform the assessment at the beginning, middle, and end of the examination and average the results

a. Watch chest movement before removing the stethoscope after counting the apical beat Because breathing is under voluntary in addition to autonomic control, clients may intentionally or inadvertently alter their breathing rate if they are aware that it is being assessed. To obtain an accurate assessment, observe respirations without alerting the client by watching chest movement before removing the stethoscope after you have completed counting the apical beat. Asking the client to breathe normally may still make the client self-conscious and prevent an accurate measurement. Observing the clients chest movement before calling the client back to the examination room would not be practical due to the distance. Performing the assessment multiple times is unnecessary and time consuming

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? a. assists the nurse in formulating appropriate subjective questioning b. allows the nurse to form an effective nurse-client relationship c. permits the nurse to initiate the assessment in a nonthreatening manner d. demonstrates the nurse's therapeutic interest in the client

a. assists the nurse in formulating appropriate subjective questioning The General Survey chapter provides an overview of the nurse's initial client assessment prior to exploring each system in detail. The objective observation of the client begins with the first moments of the encounter and continues throughout the history and physical examination. The nonverbal cues collected during the general survey enable the nurse to select appropriate subjective questions for the individual client to garner more information. While the remaining options are true statements concerning a general survey, none demonstrate the primary purpose for the collection of objective information.

An elderly client is seen by the nurse in the neighborhood clinic. The nurse observes that the client is dressed in several layers of clothing, although the temperature is warm outside. The nurse suspects that the client's cold intolerance is a result of a. decreased body metabolism. b. neurologic deficits. c. recent surgery. d. pancreatic disease.

a. decreased body metabolism. Research has shown that for older adults, normal body temperature values for all routes are consistently lower than values reported in younger populations.

The current blood pressure measurement on a 24-hour uncomplicated postoperative client while standing at the bedside is 105/65. The last two readings were 130/75 and 125/70 while resting in bed. The nurse should be alert for signs of: a. orthostatic hypotension. b. supine hypotension. c. hypertensive crisis. d. postural hypertension.

a. orthostatic hypotension.

The nurse assesses the client's vital signs as follows: respirations 20 breaths/minute, tympanic temperature 100.9°F, pulse 88 beats/minute, and blood pressure 104/64 mm Hg. The nurse should a. record the vital signs. b. instruct the client to drink more fluids. c. refer the client to a primary care provider. d. administer Tylenol.

a. record the vital signs. Validate the assessment data you have collected. This is necessary to verify that the data are reliable and accurate. Document the assessment data following the health care facility or agency policy.

The nurse assesses the amplitude of the client's radial pulse and finds it to be weak and diminished. Which of the following scores should the nurse record? a. 0 b. 1+ c. 2+ d. 3+

b. 1+ Pulse amplitude of 0 means that it is absent, 1+ that it is weak and diminished (easy to obliterate), 2+ that it is normal (can be obliterated with moderate pressure), and 3+ that it is bounding (unable to obliterate or requires firm pressure).

A female client is admitted to the health care facility due to reports of decreased appetite, loss of sleep, feelings of being unsafe in her own home, and inability to concentrate. She appears pale; her hair is disheveled, she is not wearing makeup, and she will not make eye contact. Based on this data, which nursing diagnosis can the nurse confirm? a. Imbalanced nutrition: less than body requirements b. Anxiety c. Risk for self-directed violence d. Impaired verbal communication

b. Anxiety The major defining characteristics of anxiety are present: loss of sleep, feeling unsafe, inability to concentrate, and poor eye contact. There are no major characteristics for the nursing diagnosis of imbalanced nutrition: less than body requirements, risk for self-directed violence, or impaired verbal communication.

Which abnormal skin color should a nurse anticipate assessing on a dark-skinned client? a. Yellowish b. Ashen gray c. Reddish d. Beige-pink

b. Ashen gray The skin of a dark-skinned client with cyanosis would be ashen gray. The skin tone would appear yellowish in a light-skinned client if the client had jaundice. A beige-pink skin tone would be a normal finding for the light-skinned client. A reddish skin tone could be related to fever, sunburn, or infection.

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? a. Normal b. Bradycardia c. Tachycardia d. Hypocardia

b. Bradycardia A heart rate or pulse of 60 beats per minute is termed bradycardia. Normal heart rate for the adult is between 60 and 100 beats per minute. Tachycardia describes a heart rate over 100 beats per minute. Hypocardia refers to a heart that is not beating with enough force.

Which technique demonstrates the proper positioning of the client's arm by a nurse when measuring a blood pressure? a. Client standing with arm outstretched and at the level of the heart b. Client sitting with arm slightly flexed and even with the heart c. Client's arm above the level of the heart and resting on a bedside table d. Client's arm bent at the elbow and resting on the thigh

b. Client sitting with arm slightly flexed and even with the heart Ideally, the blood pressure should be taken after the client has been in a comfortable position for 5 to 10 minutes. The blood pressure cuff should be placed against the clients skin with the bladder over the arterial pulsation. The clients arm should be slightly flexed and supported with the nurses arm. The arm should be at the level of the heart with the palm up.

The nurse is reviewing the chart of a newly admitted client and identifies the client has Marfan syndrome. What assessment finding would the nurse expect to find? a. Elongated bones of the face and hands b. Elongated fingers c. Decreased height and skeletal malformations d. Increased fat distribution in the chest, stomach and neck

b. Elongated fingers Marfan syndrome is characterized by elongated limbs and fingers. Elongated bones of the face and hands are associated with acromegaly. Client's with Cushing's syndrome exhibit weight gain in the chest, stomach and neck. Decreased height and skeletal malformations are associated with dwarfism.

During general inspection, the examiner: a. Assesses for pain and functional ability b. Integrates visual, auditory, and olfactory data c. Inquires about the client's occupational environment d. Ensures the client moves from standing to lying positions

b. Integrates visual, auditory, and olfactory data The general inspection integrates sights, smells, and sounds to form a preliminary sense of the client's status. Pain assessment and work environment are not part of the scope, and it is not necessary to position the client in a lying position at this stage.

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? a. Gigantism b. Marfan syndrome c. Anorexia d. Cushing's syndrome

b. Marfan syndrome Arm span is greater than height and pubis to sole measurement exceeds pubis to crown measurement in Marfan syndrome. In gigantism, there is increased height and weight with delayed sexual development. Extreme weight loss is seen in anorexia nervosa. Central body weight gain with excessive cervical obesity (Buffalos hump), also referred to as endogenous obesity, is seen in Cushing syndrome.

The nurse is providing care for an 83-year-old woman with a history of hypotension who has been admitted to hospital following a fall. The nurse recognizes the need to assess for orthostatic hypotension. How should the nurse perform this assessment? a. Alternate the scheduled blood pressure measurements between the standing and lying positions. b. Measure the client's heart rate and blood pressure while supine then within 3 minutes of standing. c. Measure the client's blood pressure and heart rate while she is standing then after 10 minutes of lying supine. d. Estimate systolic blood pressure by palpation while the client is lying, then measure blood pressure when the client is standing.

b. Measure the client's heart rate and blood pressure while supine then within 3 minutes of standing. Orthostatic blood pressure is measured by recording blood pressure and heart rate with the client in two positions supine after the client is resting up to 10 minutes, then within 3 minutes after the client stands up. Usually, as the client rises from the horizontal to the standing position, systolic pressure drops slightly or remains unchanged, while diastolic pressure rises slightly.

A client recovering from a stroke complains of pain. The nurse suspects this client is most likely experiencing which type of pain? a. Nociceptive b. Neuropathic c. Somatic d. Idiopathic

b. Neuropathic Neuropathic pain can occur from central nervous system brain injury caused by a stroke. Nociceptive pain is caused by tissue damage. Somatic pain is another term used for nociceptive pain. Idiopathic pain does not have an identified cause.

The nurse is admitting an elderly client with a diagnosis of congestive heart failure. Admission vital signs are respirations 38; pulse 172; blood pressure 86/72. How should the nurse best respond? a. Reassess client in one hour b. Notify the rapid response team c. Infuse IV fluids d. Administer diuretics

b. Notify the rapid response team The client is in distress. The most appropriate action of the nurse is to notify the rapid response team. The nurse cannot administer IV fluids or medications without an order Reassessing in one hour is not an appropriate action due to the client's condition.

A nurse observes the gait of an elderly client admitted for surgery. The client's gait is stiff with rigid movements. The nurse should ask this client questions about which disease? a. Chronic obstructive pulmonary disease (COPD) b. Parkinson's disease c. Lordosis of the cervical spine d. Multiple sclerosis

b. Parkinson's disease A stiff, shuffling, rigid gait is seen in persons with Parkinson's disease due to the destruction of dopamine receptors in the brain that maintain balance between contraction and relaxation of the muscles. COPD clients have no problems with gait except that activity makes them short of breath. Lordosis of the spine is seen in pregnant women and occurs in the lumbar area of the spine due to the weight of the developing fetus. Multiple sclerosis causes muscle weakness, not rigidity.

When assessing a client's pulse, the nurse is able to palpate the pulse for some time before losing it upon exerting a little bit more pressure. The pulse is beating at 80 bpm. Which of these should the nurse document as the character of the client's pulse? a. Strong pulse b. Thready pulse c. Rapid pulse d. Bounding pulse

b. Thready pulse A feeble, weak, or thready pulse describes a pulse that is difficult to feel or, once felt, is obliterated easily with slight pressure. A normal pulse is described as strong when it can be felt with mild pressure over the artery. A pulse is considered rapid when the beats exceed 100 bpm, which is not the case here. A bounding or full pulse produces a pronounced pulsation that does not easily disappear with pressure. A strong pulse is felt with a very mild pressure over the artery.

The nurse is preparing to assess the respirations of an alert adult client. The nurse should a. explain to the client that he or she will be counting the client's respirations. b. observe for equal bilateral chest expansion of 2.54 to 5.08 cm (1 to 2 in). c. count for 15 seconds and multiply the number by 4 to obtain the rate. d. ask the client to lie in a supine position, which makes counting the respirations easier.

b. observe for equal bilateral chest expansion of 2.54 to 5.08 cm (1 to 2 in). When observing respiratory depth the nurse should assess for equal bilateral chest expansion of 1 to 2 inches.

The nurse is caring for a client who is having nothing by mouth (NPO) on the first postoperative day. The client's blood pressure was 120/80 mm Hg approximately 4 hours ago, but it is now 140/88 mm Hg. The nurse should ask the client which of the following questions? a. "Are you taking any medications for hypertension?" b. "Do you have enough blankets to stay warm?" c. "Are you having pain from your surgery?" d. "What is your typical blood pressure reading?"

c. "Are you having pain from your surgery?" A client's blood pressure will normally vary throughout the day due to external influences. This includes pain.

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? a. "How is your stress level today?" b. "What vitamin supplements are you currently taking?" c. "Have you been sitting for a long time?" d. "Are you feeling feverish today?"

c. "Have you been sitting for a long time?" Sitting or standing for too long may cause the blood to pool and decrease the pulse rate. Fever and stress cause the pulse rate to increase, not decrease. Vitamin supplements do not affect the pulse rate.

A nurse has assessed the blood pressure of a recently admitted client and obtained a reading of 128/78 mm Hg. What is this client's pulse pressure? a. 128 mm Hg b. 78 mm Hg c. 50 mm Hg d. 103 mm Hg

c. 50 mm Hg The pulse pressure is the difference between the SBP and the DBP and reflects the stroke volume. Normal pulse pressure is approximately 40 mm Hg. The mean arterial pressure is calculated by adding one third of the SBP and two thirds of the DBP. A mean pressure of 60 mm Hg is needed to perfuse the vital organs.

During the physical assessment of a client, a nurse observes that the client tends to lean forward, using the arms to support the upper body. The nurse recognizes this as a sign of what disease process? a. Parkinson disease b. Osteoporotic thinning c. Chronic obstructive pulmonary disease d. Rheumatoid arthritis

c. Chronic obstructive pulmonary disease Chronic obstructive pulmonary disease (COPD) can cause clients to lean forward and brace themselves with their arms. This is known as the "tripod position" and can aid in breathing. Stiff, rigid movements are common in clients with arthritis or Parkinson disease. Osteoporotic thinning is common in older adult clients.

A client rates the current pain level as being a 5 on the Numeric Rating Scale. How should the nurse document this pain assessment? a. Patient experiencing a moderate amount of pain. b. Patient experiencing mild pain. c. Patient rated pain level as being a 5 using the rating scale. d. Patient stated "pain level not that bad."

c. Patient rated pain level as being a 5 using the rating scale. The nurse should document the exact pain assessment finding which would be "client rated pain level as being a 5 using the rating scale." The statement "client experiencing a moderate amount of pain" is a subjective statement made by the nurse and is inaccurate. The statement "client experiencing mild pain" is a subjective statement made by the nurse and is inaccurate. The statement "client stated pain level not that bad" is a subjective statement made by the client however does not identify that the client rated the pain level as being a 5 on the Numeric Rating Scale.

A nurse is preparing to assess a client's vital signs. In which order should the nurse assess them? a. Blood pressure, temperature, pulse, and respirations b. Respirations, blood pressure, pulse, and temperature c. Temperature, pulse, respirations, and blood pressure d. Pulse, temperature, respirations, and blood pressure

c. Temperature, pulse, respirations, and blood pressure When assessing the vital signs of the client, the nurse should begin by measuring the clients temperature, to put the client at ease and to quiet the client for better assessment of the remaining vital signs. Pulse, respirations, and blood pressure can be altered by anxiety and activity.

A client arrives at the emergency department by ambulance after an accident while playing softball. The client's left leg is swollen and deformed. The client describes the pain as a 9 on a 10-point scale. When the nurse assesses the client's blood pressure, what would the nurse expect to find? a. The blood pressure is lower than normal b. There would be no need to assess the blood pressure c. The blood pressure is elevated d. The blood pressure is within normal limits

c. The blood pressure is elevated Many variables affect vital signs, including pain, stress, anxiety, and activity. Pain and anxiety can contribute to increased blood pressure. The nurse would not expect to find the blood pressure lower than normal or within normal limits with the client's report of pain as a 9 on a 10-point scale. It would be expected that the nurse would assess the blood pressure upon arrival to the emergency department for this client.

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? a. There is a nonauscultatory gap b. There is a widening in the diameter of the artery c. There is an auscultatory gap d. There is an adult diastolic

c. There is an auscultatory gap An auscultatory gap is a period during which sound disappears. An auscultatory gap can range as much as 40 mm Hg. A widening in the diameter of the artery takes place in the phase II of the Korotkoff's sounds technique. An adult diastolic pressure takes place in the phase IV of the Korotkoff's sounds technique.

The nurse is assessing an elderly postsurgical client in the home. To begin the physical examination, the nurse should first assess the client's a. height and weight. b. ability to swallow. c. vital signs. d. gait.

c. vital signs. It is a good idea to begin the "hands-on" physical examination by taking vital signs. This is a common, noninvasive physical assessment procedure that most clients are accustomed to.

A nurse is assessing the pulse rate of an athletic client during a routine checkup. The nurse should anticipate the pulse rate to be in what range of beats per minute? a. 105 to 120 b. 85 to 100 c. 65 to 80 d. 45 to 60

d. 45 to 60 The normal pulse rate of a well-conditioned athletic client is often less than 60 beats per minute because of the conditioning of the cardiovascular system. A pulse rate ranging between 60 and 100 beats/min is normal for adults. A pulse rate of more than 100 beats/min would indicate tachycardia.

When can the general inspection be started? a. During the examiner's preparation to meet the client b. When the client is completely exposed c. After height and weight have been taken d. As soon as the examiner first sees the client

d. As soon as the examiner first sees the client The first moments of interaction between client and examiner should constitute the beginning of the general inspection. This should not wait until after height and weight have been measured or until the client is completely exposed. It is not possible to begin a general inspection prior to seeing (or smelling or hearing) the client.

A client has arrived to the clinic for a routine physical examination. Prior to assessing the client's blood pressure, what should the nurse do? a. Make sure the arm selected is covered with clothing. b. Palpate the radial artery to confirm a pulse is present. c. Position the arm so that it is below waist level. d. Ask the client to sit quietly in a chair for 5 minutes.

d. Ask the client to sit quietly in a chair for 5 minutes. To ensure an accurate blood pressure measurement, the nurse should ask the client to sit quietly for at least 5 minutes in a chair. The arm selected for measurement should be free of clothing. The nurse should palpate the brachial artery to confirm that it has a viable pulse. The arm should be positioned at heart level.

The nurse is beginning examination of the client. All the following areas are important to observe as part of the general survey except: a. Apparent age b. Signs of distress c. Dress, grooming, and personal hygiene d. Blood pressure

d. Blood pressure Blood pressure is a vital sign, not part of the general survey. Apparent age, signs of distress, and appearance are all parameters of the general survey.

A nurse is teaching a class on hypertension in a community setting. What risk factor would the nurse be sure to address to the class? a. Quitting cigarette smoking 5 years ago b. Loss of 50 pounds within the last 12 months c. High cholesterol and low triglyceride levels d. Family history

d. Family history Clients should be educated about the risks of hypertension. Risk factors include obesity, cigarette smoking, heavy alcohol consumption, prolonged stress, high cholesterol and triglyceride levels, family history, and renal disease. Weight loss, low triglyceride level, and smoking cessation are not risk factors for hypertension.

The nursing assistant obtains vital signs and reports a blood pressure of 180/95 to the nurse. What is the nurse's best action? a. Ask the nursing assistant to check for symptoms of hypertension. b. Document the blood pressure as an expected finding. c. Notify the healthcare provider immediately. d. Instruct the nursing assistant to obtain a manual blood pressure.

d. Instruct the nursing assistant to obtain a manual blood pressure. The best action is to verify the finding with a manual blood pressure before notifying the healthcare provider. The blood pressure is elevated and the RN should take action. The RN may delegate individual components of care, such as obtaining vital signs, but does not delegate the nursing process itself. Asking the nursing assistant to check for symptoms of hypertension is delegating assessment. Assessment is a component of the nursing process for which the RN is responsible for performing.

A nurse obtains a blood pressure on an elderly client of 160/70 mm Hg. The nurse knows that the term for this condition is what? a. Orthostatic hypotension b. Stage I hypertension c. Normal for the elderly d. Isolated systolic hypertension

d. Isolated systolic hypertension The elderly are prone to isolated systolic hypertension (systolic greater than 140 but diastolic under 90) due to arteriosclerosis that makes blood vessels stiff and less compliant. Orthostatic hypotension is a blood pressure that drops when a client changes positions. Stage 1 hypertension is a blood pressure reading of 140 to 159/90 to 99 mm Hg. Hypertension is not normal for any client.

The nurse aide reports to the nurse that an older adult client has abnormal vital signs. What is important to remember in this type of situation? a. At client's age, abnormal vital signs are an indication of something serious b. Normal readings get lower with advanced age c. Normal readings get higher with advanced age d. Normal readings vary according to age

d. Normal readings vary according to age When encountering an abnormal value, the nurse should obtain the vital sign(s) again to assess accuracy. The nurse should also consider whether the client appears to be in distress, noting skin color, respiratory effort, and behavior. Normal readings vary according to age.

When assessing a client's respirations, what is most important to include in the documentation? a. Numerical pain rating b. Position of the client c. Assessment of pedal pulses d. Presence of dyspnea

d. Presence of dyspnea The presence of dyspnea is the most important of the choices listed to include in the documentation. Dyspnea can be an indicator of potential respiratory distress. The presence of pain and position of the client can impact the client's respiratory status, but are not the primary piece of information to include in the documentation. Assessment of pedal pulses is a component of a circulatory assessment.

As adults age, the walls of their arterioles become less elastic, increasing resistance and decreasing compliance. How does this affect the blood pressure? a. The blood pressure does not change. b. The blood pressure is erratic. c. The blood pressure decreases. d. The blood pressure increases.

d. The blood pressure increases. The elasticity and resistance of the walls of the arterioles help to maintain normal blood pressure. With aging, the walls of arterioles become less elastic, which interferes with their ability to stretch and dilate, contributing to a rising pressure within the vascular system that is reflected in an increased blood pressure.

A client's blood pressure is affected by a. cardiac intake, elasticity of the arteries, blood flow, blood cells, and blood thickness. b. cardiac intake, elasticity of the veins, blood flow, blood cells, and blood thickness. c. cardiac output, distensibility of the veins, blood volume, blood velocity and viscosity. d. cardiac output, distensibility of the arteries, blood volume, blood velocity and viscosity.

d. cardiac output, distensibility of the arteries, blood volume, blood velocity and viscosity. Blood pressure is affected by cardiac output, distensibility of the arteries, blood volume, blood velocity, and blood viscosity (thickness).

The nurse should immediately notify the healthcare provider if which assessment finding is obtained on a hospitalized client? a. Temperature 37.5 Celsius b. Cyanotic left lower extremity c. Moderate amount dark blood on dressing d. Heart rate of 105 beats per minute

b. Cyanotic left lower extremity "Don't forget your ABCs: Airway, Breathing, Circulation" An acutely cold, cyanotic, or pulseless extremity should be reported to the healthcare provider immediately. A temperature below 39.0 Celsius, bright red bleeding, and a heart rate greater than 120 beats per minute or less than 50 beats per minute are not considered urgent findings

You are educating your client on taking blood pressure at home. What would be important to include in your client education? a. Monthly replacement of batteries b. Routine recalibration of the device c. Application of a thigh cuff d. Use of a wrist cuff

b. Routine recalibration of the device Follow the guidelines listed, and advise your clients about how to choose the best cuff for home use. Urge them to have their home devices recalibrated routinely.

Since the nurse is unable to obtain an oversized cuff to assess an adult client with a large arm, the nurse uses an average-sized cuff. What blood pressure reading will the nurse most likely obtain for this client? a. Correct reading b. Reading will be low c. Reading will be high d. Reading cannot be obtained

c. Reading will be high If the blood pressure cuff used is too small and the client's arm is large, the blood pressure reading will be high. If the blood pressure cuff is too large and the client's arm is small, the reading will be low. The reading obtained with an inappropriately sized cuff will not be correct. The reading can be obtained; however, the reading will be incorrect.

A nurse is assessing the respiratory rate of an elderly client. Which of the following findings in breaths per minute would indicate a normal respiratory rate in this client? a. 11 b. 23 c. 12 d. 18

d. 18 A respiratory rate of 18 breaths/min would be normal for this client. In older adults, the normal respiratory rate would range between 15 and 22 breaths/min. Respiratory rates of fewer than 15 breaths/min or more than 22 breaths/min would be an abnormal respiratory rate for this client.