PrepU Chapter 05: Vital Signs and General Survey
A nurse at an ambulatory clinic is preparing to begin the collection of objective assessment data from a female client. After meeting the client and bringing her into the examination room, what instruction should the nurse provide?
"Please have a seat on the edge of the exam table."
Which statement by a nurse concerning the various methods used to measure temperature indicates the need for additional education?
"When monitoring the same client, an axillary temperature is usually higher by a degree than an oral temperature."
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?
50 mm Hg
Student nurses are taking vital signs at a community screening clinic. The nursing instructor should intervene when the student nurse performs which of the following actions?
Applies the cuff to the right arm above the client's shunt location.
A nurse assesses a newly admitted 43-year-old client and documents the vital signs as follows: temperature 98° F (36.7° C), pulse 93 beats/min regular rhythm and bounding, blood pressure 145/93 mm Hg, and respiratory rate 16 breaths/min. What is the first action of the nurse?
Ask the client if they are experiencing other symptoms.
The nurse palpates a client's pulse and notes that the rate is 71 beats per minute, with an irregular rhythm. How should the nurse follow up this assessment finding?
Auscultate the client's apical pulse.
The nurse explains to the client that smoking has what effect on the body? Select all that apply.
Hypertension Vasoconstriction Peripheral vascular diseas
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 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
In interviewing a client about his heart rate, the nurse asks whether he has noticed any alteration to his heartbeat. The client responds that he sometimes feels his heart race even when he has not been exerting himself physically. This alteration is known as which of the following?
Palpitation
A nurse in the surgical daycare department has called a client in from the waiting room and is meeting the client for the first time. The nurse immediately observes that the client has a noticeably "stooped" posture. How should the nurse best follow up this abnormal assessment finding?
Perform a focused assessment of the client's musculoskeletal system
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 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?
Rigid
In which order should a nurse assess a client's vital signs?
Temperature, pulse, respiration, and blood pressure
As adults age, the walls of their arterioles become less elastic, increasing resistance and decreasing compliance. How does this affect the blood pressure?
The blood pressure increases.
Which of the following would the nurse need to keep in mind when assessing the blood pressure of a client who is receiving anticoagulant therapy?
The blood viscosity would be thinner, causing the blood pressure to decrease.
The nurse is assessing the oxygen saturation of a client. What consideration(s) should the nurse take into account when performing this assessment? Select all that apply.
diagnosis of emphysema removal of nail polish palpable pulse on the chosen extremity for the reading presence of capillary refill
Osteoporotic thinning and collapse of the vertebrae secondary to bone loss in an elderly client may result in
kyphosis
Which of the following is a normal temperature in centigrade for a healthy adult?
oral: 36.8°C
A client, sipping hot tea, is scheduled for routine vital signs. Which illustration shows the leastappropriate method for the nurse to use to obtain an accurate temperature reading?
picture: nurse taking oral temperature of client
