NURS 305 Chapter 30

The nurse reviews documentation that indicates that a patient with hypertension has an auscultatory gap. Specific to this finding, which actions should the nurse take when measuring this patient's blood pressure?

Patients with hypertension may have an auscultatory gap where the sound disappears between the first and second Korotkoff sound. Therefore, when measuring the blood pressure, the nurse should listen to the Korotkoff sound until the cuff is completely deflated. Making sure that the bell of the stethoscope is placed firmly over the artery helps to hear the Korotkoff sound clearly. Stopping midway and beginning to inflate again may give a false reading. Pumping up the cuff until no sound is heard and then slowly releasing the air is a part of regular blood pressure measurement and is not specific to a patient with an ausculatory gap. The examiner needs to be certain to inflate the cuff high enough to hear the true systolic pressure before the auscultatory gap. p. 508

Which factor is associated with a 0.5 to 1° C change in body temperature during a 24-hour period?

Temperature is one of the most stable rhythms in humans. Circadian body temperature rhythm normally changes 0.5 to 1° C (0.9 to 1.8° F) during a 24-hour period. Physical and emotional stress increases body temperature through hormonal and neural stimulation, but these stressors are not associated with a 0.5 to 1° C change in body temperature during a 24-hour period. Prolonged strenuous exercise, such as long-distance running, temporarily raises body temperature. Hormonal variations during the menstrual cycle cause body temperature fluctuations. Woman who have stopped menstruating often experience periods of hot flashes, in which skin temperature increases up to 4° C (7.2° F). p. 490

Which drug class is mainly used to reduce heat production?

Although corticosteroids are not used to treat fever, they reduce the production of heat by interfering with the hypothalamic response. Beta-adrenergic drugs are used to block the sympathetic nerve impulses. Calcium channel blockers reduce peripheral vascular resistance by systemic vasodilation. Nonsteroidal antiinflammatory drugs are used to reduce body temperature. p. 496

A patient on benazepril for hypertension asks the nurse about how the medication works. Which statements are appropriate responses by the nurse?

Benazepril is an angiotensin-converting enzyme (ACE) inhibitor. It lowers blood pressure by lowering the circulating blood volume, by producing vasodilation of blood vessels, and by reducing aldosterone production and water retention. Beta-adrenergic blockers, not benazepril, act by reducing the heart rate and cardiac output. p. 505

A patient has abnormally shallow respirations followed by irregular periods of apnea. What term does the nurse use to record this breathing pattern?

Biot's respiration is the presence of abnormally shallow breaths followed by irregular periods of apnea. The cessation of respiration for several seconds is called apnea. Bradypnea is a regular, slow respiration of less than 12 breaths per minute. Kussmaul's respiration is an abnormally deep, regular, and increased rate of respiration. p. 502

Which statement is true about body temperature?

Body temperature is the difference between the amount of heat produced by body processes and the amount of heat lost to the external environment. Body temperature is not the amount of heat produced by body processes or the amount of heat lost to the external environment, nor is it the sum of the amount of heat produced and the amount of heat lost. p. 488

A patient has a heart rate of 80 beats per minute and a stroke volume of 60 mL per beat. What is the cardiac output that the nurse records for the patient? Record your answer using a whole number, and please note, no comma is needed.

Cardiac output is the product of heart rate and stroke volume. Hence, the cardiac output in the patient is 80 × 60 = 4800 mL. p. 497

A hospital replaces all sphygmomanometers with electronic blood pressure (BP) devices. In which situations is the use of electronic devices not recommended?

Electronic devices cannot be used to measure BP in any situation in which the patient cannot be kept still such as in seizures and shivering. An irregular heart rate would interfere with the BP measurement, so electronic BP measurement cannot be done in such patients. Electronic blood pressure devices are unable to process sounds or vibrations of low BP; thus it would not be helpful to measure BP in severe hypotensive states. Electronic devices are not appropriate if the patient has excessive tremors. p. 509

Which heat loss mechanism involves the transfer of heat away by air movement?

Heat loss and heat production occur simultaneously. There are four types of heat loss mechanisms: radiation, convection, conduction, and evaporation. Convection is the transfer of heat away by air movement. Radiation is the transfer of heat from the surface of one object to the surface of another, without direct contact between the two. Conduction is the transfer of heat from one object to another with direct contact. Evaporation is the transfer of heat energy when liquid is changed to a gas. p. 489

The nurse suspects a patient of having heatstroke. Which signs and symptoms should the nurse look for in the patient?

Heatstroke is a condition in which the body temperature is 104° F (40° C) or greater. It may happen due to imbalance in heat loss mechanisms of the body caused by prolonged exposure to the sun or a high environmental temperature. The signs and symptoms of heatstroke include nausea, excessive thirst, and visual disturbances. Bradycardia and cyanosed skin are symptoms of severe hypothermia. p. 491

A patient has been brought to the emergency department (ED) after falling into a frozen lake. Which body parts should the nurse first assess for the presence of frostbite in the patient?

Peripherally exposed areas such as the earlobes, nose, toes, and fingers are more susceptible to developing frostbite because of poor circulation to those areas. Generally, one does not find frostbite in the central areas such as the thighs, chest, and shin of the leg because of the rich blood supply. p. 491

The nurse is teaching a patient who is taking antihypertensive drugs about the management of hypertension. Which statement would indicate that the patient understands the management of hypertension?

The drug therapy for high blood pressure does not cure the disease; it only helps control the symptoms. Patients should check blood pressure regularly, report significant changes, and avoid the use of tobacco in any form. The blood pressure would return to normal with the drug therapy; however, therapy should not be stopped or hypertension may return. p. 505

A patient presents with heat stroke. How does the nurse manage the treatment of the patient?

The first treatment for heat stroke includes the use of oscillating fans to promote conductive heat loss from the body, removing excessive clothing, and irrigating the stomach with cool solutions. Hypothermia blankets are helpful in reducing the body temperature of the patient having a heat stroke. Having a heatstroke does not indicate that the patient has an infection, thus the nurse should not be administering IV antibiotics to the patient. p. 497

Bradypnea would be defined by the nurse as any respiratory rate less than _______ breaths/minute.

The normal respiratory rate for an adult is 12 to 20 breaths/minute. Bradypnea is said to be present when breathing is regular and abnormally slow, in other words, less than 12 breaths/minute. p. 502

On examination, the nurse finds that a patient has a temperature of 104° Fahrenheit. What would the temperature be in Celsius?

When it is necessary to convert temperature readings from Fahrenheit to Celsius, subtract 32 from the Fahrenheit reading and multiply the result by 5/9. Use the formula C = (F - 32) × 5/9, where C represents Celsius and F represents Fahrenheit. Thus, 104 - 32 is 72, multiplied by 5/9 = 40° C.

A patient presents to an emergency room with a high body temperature. Which nursing measures does the nurse implement to reduce the patient's body temperature?

A fan promotes the loss of heat through convection. Heat loss through conduction can be encouraged by the application of ice packs and bathing the patient with a cool cloth. Aquathermia pads help the body gain heat through conduction; they do not promote heat loss. Covering the body with dark and closely woven clothes reduces heat lost from radiation; the clothes will not decrease the patient's body temperature. pp. 496-497

The registered nurse (RN) is teaching a nursing student about common errors and their effects when assessing blood pressure (BP). Which statements by the nursing student indicate the need for further teaching?

A few common errors can occur while measuring blood pressure (BP). An improperly fitted cuff or the rate in which the cuff inflates and deflates can cause inaccurate BP measurements. For instance, inflating the cuff too slowly may cause false-high diastolic readings. Inadequate inflation level may cause false-low systolic readings. Repeating the assessments too quickly may cause false-high systolic readings. Placing the patient's arm below the heart level may lead to false-high readings. Applying the stethoscope too firmly against the antecubital fossa may lead to false-low diastolic readings. p. 507

The registered nurse (RN) is reviewing the clinical data of four older patients. Which patient is at the greatest risk of cardiac arrest?

A respiratory rate greater than 27 breaths/minute is an important risk factor for cardiac arrest. Patient A with a respiratory rate of 29 breaths/minute is at a greater risk of cardiac arrest than the other patients. Patient B with a blood pressure of 139/89 mm Hg indicates a greater risk for hypertension, but not cardiac arrest. Patient C with a partial pressure of arterial carbon dioxide (PaCO 2) of 35 mm Hg has normal findings and may not be at a risk of cardiac arrest. Patient D with a pulse rate of 70 beats/minute indicates normal blood pressure, not risk of cardiac arrest.

The nurse is teaching about hypertension management to a patient who is taking antihypertensive drugs. Which statement made by the patient indicates a need for further clarification?

Compliance with antihypertensive therapy is difficult for two reasons. First, patients often have no distressing symptoms associated with hypertension and might not believe they have a problem. Second, many patients believe that once blood pressure is brought back into the normal range, they are cured and no longer need to take medication. Losing weight reduces the need for blood pressure medications by promoting easy blood flow through the circulatory system. Hypertension increases the risk of having a heart attack. Keeping the blood pressure under control also decreases the risk of heart attack. The patient may feel dizzy when getting up suddenly from a sitting or lying down position due to hypotension. Therefore, the patient should sit for a few moments first and then stand. pp. 504-505

Which site would the nurse choose to document continuous core temperature while the patient is in the intensive care unit?

Core temperatures can be measured at several sites. Intensive care units use the core temperatures of certain sites such as urinary bladder, esophagus, or pulmonary artery. Axillae are not recommended as a site of temperature measurement, because they have been shown to be inaccurate and to poorly reflect core temperature. The nurse would use the rectum and the tympanic membrane as sites of measurements when intermittent temperature measurements are required. p. 492

A patient is admitted to the hospital with high fever. The healthcare provider tells the nurse to administer a drug to decrease heat production in the patient. Which drug will most likely be prescribed to this patient?

Corticosteroids reduce heat production by interfering with the immune system. As a result, they bring down the temperature of the patient. Salicylates, indomethacin, and acetaminophen reduce the body temperature by promoting heat loss from the body. p. 496

An elderly patient has recently shifted to a residence located at a high altitude and finds it difficult to cope with extreme temperatures. The patient feels that there is a body system problem because the patient experiences more cold than other people do. The nurse explains to the patient that this is a normal response to aging. What is the rationale for this response?

Elderly people have poor vasomotor control. There is inefficient vasomotor regulation in response to alterations in temperature. Fat and subcutaneous tissues play a major role in insulation. There is reduction of subcutaneous tissue in aging. The activity of the hypothalamus and thus the temperature control mechanism also deteriorates with aging. Metabolism and sweat gland activity decrease with aging, making the temperature control mechanism less effective. p. 489

The nurse is reviewing the clinical data of 4 patients. Which patient is experiencing a remittent pattern of fever?

Fevers and fever patterns serve a diagnostic purpose. Fever patterns differ depending on the causative pyrogen. The increase or decrease in pyrogen activity results in fever spikes and declines at different times of the day. In a remittent fever pattern, temperature spikes and falls without returning to acceptable temperature levels as exemplified by patient C, whose temperature fluctuates between 39.7° C (103.4° F) and 38.7° C (101.6° F) for two days. Patient A with a body temperature of 100.4° F throughout the day with little fluctuation is experiencing a sustained fever. Patient B with a body temperature of 103.4° F throughout the day and 98.4° F during the night is showing signs of an intermittent fever pattern. Patient D with a body temperature fluctuating between 101.3° F and 98.4° F every other day is experiencing a relapsing fever. p. 491

A patient is admitted to the hospital with complaints of pallor, skin mottling, clamminess, and confusion. The nurse assessed the vitals and found that the blood pressure was 90/60 mm Hg. She immediately reported it to the health care provider. What could be the cause of the patient's low blood pressure?

Hypotension (low blood pressure) occurs because of arterial dilation or considerable bleeding (e.g., hemorrhage) or the failure of the heart muscle to pump adequately (e.g., myocardial infarction). Modifiable risk factors for hypertension, rather than hypotension, include obesity, cigarette smoking, heavy alcohol consumption, and high sodium (salt) intake. Sedentary lifestyle and continued exposure to stress are also linked to hypertension. p. 505

A patient was brought to the emergency department following a motor vehicle accident. The surgeon performs surgery and intentionally induces hypothermia. What does the nurse infer about the reason for inducing hypothermia?

Hypothermia occurs when the body is exposed to cold temperatures for a prolonged period of time. Occasionally hypothermia is intentionally induced during surgical or emergency procedures to reduce the metabolic demands of the body, as well as to reduce the body's oxygen supply requirements. When the patient experiences heat exhaustion, the primary intervention should be to cool the environment near the patient and restore fluids and electrolytes. Heat production should be reduced when the patient has hyperthermia. Hypothermia is not induced in the patient to overwhelm the heat-loss mechanisms, but is rather induced to reduce the metabolic and oxygen demands in the body. p. 491

A patient reports to the nurse increased body temperature in the evening and decreased body temperature in the morning. What does the nurse educate this patient about normal circadian rhythms?

In a normal circadian rhythm, the normal body temperature is highest at around 4:00 pm and lowest between 1:00 am and 4:00 am. The temperature change during a 24-hour period is usually between 0.5° C and 1° C. The circadian temperature rhythm does not alter with age. In night-shift workers, the temperature pattern does not change automatically within one week of beginning the night shift. It takes up to 3 weeks for such a change to happen. p. 490

A patient has regular but abnormally rapid respirations of more than 20 breaths per minute. What term does the nurse use to record this breathing pattern?

In tachypnea, patients exhibit regular but rapid breathing of more than 20 breaths per minute. Hyperpnea is labored respiration associated with increased rate and depth. Hyperventilation is an increase in the rate and depth of respiration. Cheyne-Stokes respiration is characterized by alternating periods of apnea and hyperventilation. p. 502

The nurse notices intense body warmth and sweating lasting for up to 5 minutes in a 50-year-old woman. How does the nurse interpret these symptoms?

Intense body warmth and sweating in a menopausal woman indicate that she is having hot flashes. They occur due to instability of the vasomotor controls for vasodilation and vasoconstriction. They are due to vascular changes and not due to neurogenic changes. In menopause, there is a decreased estrogen level. Hot flashes are a symptom of menopause, and may not be due to fever. p. 490

While assessing a patient with a fever, the nurse notices a spike in body temperature and the temperature returning to the acceptable limits within a 24-hour period. Which fever pattern is the patient experiencing?

Intermittent fever pattern is associated with fever spikes interspersed with returns to normal temperature levels at least once in 24 hours. With a sustained fever pattern, the body temperature is continuously above 38° C (100.4° F) with little fluctuation. Periods of febrile episodes alternating with periods of acceptable temperature values, both lasting longer than 24 hours, are indicative of relapsing fever. With remittent fever, temperature spikes and falls without returning to acceptable temperature levels. p. 491

A diabetic patient with poor glycemic control has been admitted to the intensive care unit (ICU). The nurse observes that the patient is breathing deeply. The respiration rate is regular and increased. What should the nurse label this type of respiratory pattern?

Kussmaul's respiration is an abnormally deep, regular, and increased rate of respiration seen in conditions associated with metabolic acidosis such as in a diabetic patient. Biot's respiration is shallow and associated with irregular periods of apnea. Bradypnea is regular but the rate of respiration is reduced. Cheyne-Stokes' respiration is an irregular rate and has a depth of respiration associated with periods of apnea and hyperventilation. p. 502

Why is the temperature of deep tissues in older adults lower than that of young adults?

Temperature of the deep tissues, also known as core temperature, is relatively constant compared to surface temperature. This is because it varies depending on blood flow to the skin and the amount of heat lost to the external environment. In the older adult population, the average core temperature ranges from 35 to 36.1° C (95 to 97° F), as a result of decreased immunity. For healthy young adults, the average oral temperature is 37° C (98.6° F). Decreased temperature in the deeper tissues of the older adults may not be due to decrease in skin turgor. Increased blood pressure may increase heart rate and thereby increase body temperature. Increased basic metabolism rate increases the body temperature, but may not decrease it. p. 488

The nurse is measuring a patient's blood pressure. Where should the nurse locate the pulse to auscultate blood pressure?

The brachial pulse is used when measuring blood pressure. It can be located in the groove between the biceps and triceps muscles at the antecubital fossa. The radial pulse is located at the thumb side of the forearm at the wrist. This pulse is used to assess the circulation to the hand. The ulnar pulse is located at the ulnar side of the forearm at the wrist. This pulse is used to assess the circulatory status to the hand and to perform Allen's test. The apical pulse can be palpated at the fourth to fifth intercostal space at the left midclavicular line. p. 508

An older adult patient was brought to the hospital after a cardiac arrest, and is being treated and kept under observation. The nurse finds that the patient's condition is suddenly worsening. Which site should the nurse immediately assess to obtain the patient's pulse?

The carotid artery is the most suitable site for assessing the patient's pulse, because it can be located quickly and provides a good reading on the pulse, as the heart delivers blood through the carotid artery. The ulnar site is used for assessing the status of circulation to the hands. The popliteal site is used to assess the status of circulation to the lower leg. The temporal site is used to assess pulse in pediatric patients. p. 49

In which patient would a resting heart rate of 55 beats/minute be considered a normal finding?

The conditioning of athletes, especially runners, allows a resting rate below 60 beats/minute without interrupting the normal sinus rhythm of the heart. A heart rate below 60 beats/minute is considered bradycardia. Athletes often maintain heart rates consistent with sinus bradycardia because their heart is an effective pump with a greater-than-normal stroke volume. An obese person may experience an increase in resting heart rate secondary to cardiac demand. Bradycardia is not associated with diuretics or weight less than 90 lbs. p. 499

An infant has a fever and is sweating. The pediatrician asks the nurse to measure the patient's temperature. Which action by the nurse is correct?

The nurse would measure the temperature at the tympanic membrane site because the patient has excessive sweating, which can alter the readings at external sites. The rectal site is not advised for checking routine vitals such as temperature in the newborns. The skin and temporal artery are not suitable sites for temperature measurement when the patient is sweating, because sweating or diaphoresis may impair the adhesion. p. 493

A patient is admitted to a surgical unit after repair of a fractured left arm and left leg following a motor vehicle accident. An intravenous (IV) line is infusing in the right antecubital fossa, and pneumatic compression stockings are on the right lower leg. Oxygen is being administered via a simple face mask. Which sites should be used for obtaining the patient's blood pressure and temperature?

The only extremity that does not have a compromised artery to auscultate for a blood pressure would be the right lower leg after the sequential device is removed. The oral site for temperature is contraindicated with face mask oxygen therapy. p. 493, 508

The registered nurse is training nursing students and asks the students to convert the patient's body temperature values from Fahrenheit to Celsius. The patient's body temperature reads 106° F. What is the Celsius reading of the patient's temperature? Record your answer to the nearest tenth.

The patient's body temperature is 106° F. To convert the Fahrenheit readings to Celsius, 32 must be subtracted from the given Fahrenheit reading to equal 74. The remainder should be multiplied by 5/9 to equal a Celsius reading of 41.1° C. C = (F - 32) × 5/9 C = 106°F - 32 = 74 C = 74 × 5/9 = 41.1° C p. 492

A healthcare provider instructs the nurse to palpate the posterior tibial artery. Which site does the nurse use?

The posterior tibial artery is palpated on the inner aspect of the ankle, below the medial malleolus. The dorsalis pedis artery is palpated along the top of the foot. The popliteal artery is palpated within the popliteal fossa. No artery is palpated along the lateral malleolus. p. 498

A patient complains of numbness in the foot for the past two days and consults the primary health care provider (PHP). The PHP asks the nurse to assist while performing a pulse assessment on the foot to ensure proper circulation. Which sites would be appropriate for the pulse assessment?

The posterior tibial site is located at the inner side of the ankle, below the medial malleolus, and is used to assess circulation to the foot. The dorsalis pedis is located along the top of the foot, between extension tendons of the great and first toe, and is used for assessing circulation to the foot. The ulnar site is used to assess circulation to the hand. The radial site is located near the thumb side of the forearm at the wrist, and is commonly used to assess the character of the pulse peripherally and circulation to the hand. The brachial site is used to assess circulation to the lower arm. p. 498

The nurse has been asked to record the nature of the pulse in a patient. What peripheral pulse is the most common and easiest to assess for pulse rate assessment?

The radial site is commonly used for assessing the nature of the pulse and is also used for assessing circulation to the hands. The carotid site is easily accessible and is used during shock and cardiac arrest when other sites are not palpable. The brachial site is suitable for assessing circulation in the upper limb and auscultating blood pressure. The temporal site is easily accessible and is suitable for assessing the pulse in children. p. 497

Which site is appropriate for assessing the pulse in children?

The temporal site is easily accessible and is suitable for assessing a pulse in children. The radial site is used to assess the status of circulation to the hands. The carotid site is easily accessible and is used during shock and cardiac arrest when other sites are not palpable. The femoral site is an easily accessible site during shock and cardiac arrest, and this site is suitable for assessing circulation in the legs. The brachial or apical pulse is the best site for assessing the pulse in an infant or young child. pp. 497, 498

A patient reports fever and chills. The nurse reviews the case sheet and finds that the patient has a history of otitis media and is taking medication. Which temperature measurement site would the nurse avoid for this patient?

The tympanic membrane is present in the ear. If the patient has otitis media, it is not recommended to perform temperature measurement at this site, because otitis media and cerumen impaction distorts readings. Skin can be used to measure temperature for a patient who is on medication for otitis media. The oral cavity is a recommended site of measurement for stable patients. Rectal temperatures are taken when oral temperature is difficult or impossible to obtain. p. 493

Which pulse assessment site is also used when performing Allen's test?

The ulnar site is located near the little finger side of the forearm at the wrist. This site is used to assess circulation to the hand and is also used to perform Allen's test. The apical site is located near the fourth to fifth intercostals space at the left midclavicular line, and is used to auscultate for apical pulse. The brachial site is located the in the groove between the biceps and triceps muscles at the antecubital fossa and is used to assess circulation to the lower arm. The femoral site is below the inguinal ligament, midway between symphysis pubis and anterior superior iliac spine.

The nurse is assessing a patient who has just been rescued after falling into a frozen lake. The patient's body temperature has fallen below 93.2° F (34° C). Which signs should the nurse expect the patient to show?

This is a typical case of accidental hypothermia in which the patient shows signs such as uncontrolled shivering and cyanosis; cardiac dysrhythmias may occur in later stages. The body may try to generate heat to counteract hypothermia by shivering. Hypothermia results in a decreased blood supply to the peripheral organs, resulting in cyanosis. Cardiac dysrhythmias may occur because the cells of the body cannot function at low temperatures. Blood pressure and respiratory rate tend to fall in hypothermia. p. 491

You observe a nursing student taking a blood pressure (BP) reading on a patient. The patient's BP range over the past 24 hours was 132/64 to 126/72 mm Hg. The student used a BP cuff that was too narrow for the patient. Which BP reading made by the student is most likely caused by the incorrect choice of BP cuff?

When you use a blood pressure cuff that is too narrow or short, your patient will most likely have a BP reading that is higher than it really is: You will get a false-high reading. If the bladder or cuff were too wide, the reading would be a false-low reading. pp. 506, 507