Nursing - Fundamentals of Nursing Vital Signs

What would be the follow-up recommendation suggested by the primary health care provider to a patient with stage 1 hypertension?

1 month For a patient with stage 1 hypertension, the recommendation for blood pressure follow-up would be 1 month. For a patient with stage 2 hypertension, the recommendation for blood pressure follow-up would be within 1 month. For those with higher pressure (e.g., >180/110 mm Hg), evaluate and treat immediately or within 1 week, depending on clinical situation and complications. Prehypertension patients require recheck in 1 year. Patients with normal blood pressure would require recheck in 2 years.

A nurse is performing an admission assessment on a client. The nurse determines the client's radial pulse rate is 68/min and the simultaneous apical pulse rate is 84/min. Which the client's pulse deficit?

16/min. It's the difference between the apical and radial pulse rates. 84-68=16.

At which age does the respiratory system begin to decline in healthy people?

25 years The respiratory system begins to decline in healthy people after the age of 25. The respiratory system matures by the time a person reaches 20 years of age. Despite the decline in adults at 45 and 60 years of age, they can breathe effortlessly as long as they are healthy.

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. __________ °C

41.1* 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

Which statement is true regarding respiration?

A respiratory rate above 27 breaths per min is a risk for cardiac arrest. The normal respiratory rate range varies with age. If the respiratory rate is above 27 breaths per minute, it is a risk factor for cardiac arrest. The normal respiratory rate for newborns is 30 to 60 breaths per minute. The apnea monitoring device is used frequently with infants in the hospital and at home to observe patients at risk for prolonged apneic attacks. The normal respiratory rate range declines throughout life; it does not remain constant.

A nurse is caring for an 82-year-old client in the emergency department who has an oral body temperature of 38.3 C(101 F), pulse rate 114/min, and respiratory rate 22/min. He is restless and his skin is warm. Which of the following interventions should the nurse take? (select all that apply)

A. Obtain culture specimens before initiating antimicrobials. C. Encourage the client to rest and limit activity. E. Assist the client with oral hygiene frequently.

A nurse is instructing a group of nursing students in measuring a client's respiratory rate. Which of the following guidelines should the nurse include? (select all that apply)

A. Place the client in semi-Fowler's position B. Have the client rest an arm across the abdomen C. Observe one full respiratory cycle before counting the rate

A nurse who is admitting a client who has a fractured femur obtains a blood pressure reading of 140/94 mm Hg. The client denies any history of hypertension. Which of the following actions should the nurse take first?

Ask the client if she is having any pain(first nursing process of assessment)

A community health nurse understands that heat stroke is more common among certain professionals. Which professionals are at a higher risk for having a heat stroke? Select all that apply.

Athletes Farmers Construction workers Athletes exercise a lot and may suffer from heat stroke. Farmers and construction workers tend to do strenuous physical, outdoor activity, predisposing them to heat stroke. Teachers and office workers do not generally engage in strenuous outdoor work and are not at risk of developing a heat stroke.

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?

Carotid site 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.

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

Decreased immunity 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.

A nurse instructing an assistive personnel (AP) about caring for a client who has a low platelet count as result of chemotherapy. Which of the following instructions is the priority for measuring vital signs for this client?

Do not measure the client's temperature rectally because it the greatest risk of the rectal mucosa.

The registered nurse delegated the task of palpating the pulse of a 75-year-old obese patient to a licensed practical nurse (LPN). Which device used by the LPN would be appropriate to obtain more accurate readings in this patient?

Doppler device A Doppler device is used to palpate the pulse of an older adult who is obese because it provides more accurate readings. An apnea monitor is a device used to measure respiratory rate. A pulse oximeter is used to measure oxygen saturation and the values obtained with this device are less accurate. The vinyl pressure cuff is used to measure blood pressure.

A patient reports a loss of sensation in the fingers and toes after being exposed to cold temperatures. Upon assessment, the nurse observes the injured area becoming white, waxy, and firm to the touch. What condition do these signs and symptoms likely indicate?

Frostbite Frostbite occurs when the body is exposed to subnormal temperatures. Ice crystals form inside the cells, and permanent circulatory and tissue damage occurs. Areas particularly susceptible to frostbite are the earlobes, tip of the nose, fingers, and toes. The injured area becomes white, waxy, and firm to the touch. Heatstroke occurs due to prolonged exposure to the sun, or a high environmental temperature overwhelms the heat-loss mechanisms of the body; it is usually accompanied by uncontrolled shivering, loss of memory, and poor judgment. Heat loss during prolonged exposure to cold overwhelms the body's ability to produce heat, causing hypothermia. Heat exhaustion occurs when profuse diaphoresis results in excess water and electrolyte loss, caused mainly by environmental heat exposure.

Which condition is a result of the heat-loss mechanisms of the body becoming overwhelmed?

Heatstroke Prolonged exposure to the sun or a high environmental temperature overwhelms the heat-loss mechanisms of the body. These conditions cause heatstroke, defined as a body temperature of 40° C (104° F) or more. Frostbite occurs when the body is exposed to subnormal temperatures. Ice crystals form inside the cells, and permanent circulatory and tissue damage occurs. Heat loss during prolonged exposure to cold overwhelms the ability of the body to produce heat, causing hypothermia. Heat exhaustion occurs when profuse diaphoresis results in excess water and electrolyte loss.

The nurse is teaching a patient to monitor his/her heart rate. This action occurs during which step in the nursing process?

Implementation Teaching patients how to monitor their own heart rate occurs during the implementation step of the nursing process. When the nurse is monitoring the heart rate of the patient, it is considered an assessment. Planning involves preparing for the assessment of vital signs and monitoring of the patient. Evaluation involves analyzing the values obtained during the assessment tests and determining whether outcomes were met.

The nurse is collecting a patient history from a 50-year-old perimenopausal woman. Which clinical manifestation would be expected on patient report of symptoms?

Intense body heat and episodes of sweating Intense body warmth and sweating are characteristic symptoms during the perimenopausal period. They are believed to be due to an imbalance (loss of) estrogen as well as instability of the vasomotor controls for vasodilation and vasoconstriction. The perimenopausal period is characterized by shorter nighttime sleep and/or disrupted sleep, not extended sleep. The perimenopausal woman will frequently complain of feeling hot, not chilled; and gaining weight, not losing weight, related to the changes in reproductive hormone levels.

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 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.

The nurse understands that patients with dysrhythmias may have a pulse deficit. How should the nurse calculate the pulse deficit?

It is the difference in the pulse rates of the apical and radial pulses. A pulse deficit is created when an inefficient contraction of the heart fails to transmit a pulse wave to the peripheral pulse site. A pulse deficit is the difference in the apical and radial pulse rates. There is usually no difference in the left and right radial pulse rates or in the left and right femoral pulse rates. A pulse deficit does not indicate a difference in the radial and femoral pulse rates.

Which statement is true regarding the pulse rate of an older adult?

It takes longer for the heart rate to rise in older adults during illness. It takes longer for the heart rate to rise in the older adults during illness to meet increased demands during conditions such stress, illness, and excitement. Pedal pulses are often difficult to palpate in older adults. Older adults have decreased heart rate at rest. Heart sounds are sometimes muffled or difficult to hear in older adults because of an increase in air space in the lungs.

Which requirement is necessary for measuring oxygen saturation in a patient with emphysema?

Oximeter An oximeter is used to measure oxygen saturation by pulse oximetry. Lubricants are used to measure rectal temperature. An aneroid sphygmomanometer is used to measure blood pressure. A wrist watch with a second hand display is used to measure radial or apical pulse.

Which manifestation is often called the fifth vital sign?

Pain Pain, a subjective symptom, is often called the fifth vital sign because it is an indicator of health status and, therefore, it is frequently measured with other vital signs. Pulse, temperature, blood pressure, and respiration are the main vital signs because they indicate the effectiveness of circulatory, respiratory, neural, and endocrine body functions.

While assessing the rectal temperature of a patient, the nurse slides a plastic disposable probe cover over the thermometer probe stem until the cover locks in place. What is the reason behind this intervention?

Preventing transmission of microorganisms between patients Sliding a disposable plastic probe cover over the thermometer probe stem will prevent the transmission of microorganisms between patients. Squeezing a liberal portion of lubricant on the tissue helps lubricate the rectal mucosa and minimizes trauma. Application of clean gloves between cleaning the anal region and measuring rectal temperature is important to maintain standard precautions. Inserting the thermometer probe gently into the anus in a direction of umbilicus 2.5 to 3.5 cm helps ensure adequate exposure against blood vessels in the rectal wall.

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?

Radial 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.

A patient has delivered a baby at full term. What does the nurse teach the patient about protecting newborns from environmental temperature? Select all that apply.

Teach the importance of adequate clothing. Emphasize covering the head of the baby with a cap. Instruct the patient to avoid exposing infants to extreme temperatures. The temperature control mechanism of newborn babies is immature, and babies respond drastically to environmental temperatures. Hence, babies should be adequately clothed, and the head of the baby should be covered by a cap to prevent heat loss. Newborn babies should not be exposed to extreme temperatures; extreme temperatures can harm them. The body temperature should be kept between 95.9° F (35.5° C) and 99.5° F (37.5 ° C), because this is the normal range of body temperature for newborns; temperatures above 99.5° F (37.5 ° C) indicate fever.

Which site should be used by the nurse to determine pulse in children?

Temporal The temporal site, which is present over the temporal bone of the head, above and lateral to the eye, should be assessed in children to determine pulse. The apical site is used to auscultate for the apical pulse. The carotid site can be accessible during physiological shock or cardiac arrest when other sites are not palpable. The brachial site is used to assess the status of circulation to the lower arm and to auscultate blood pressure.

Which site is preferred by the nurse to perform Allen's test?

Ulnar The ulnar region is the site used to assess the status of circulation in the hand and also used to perform Allen's test. The radial site is commonly used to assess the character of the pulse peripherally and the status of circulation to the hand. The femoral site is used to assess the character of the pulse during physiological shock or cardiac arrest. The temporal region is an easily accessible site to assess pulse in children.

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

Ulnar site 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.