PrepU Chapter 5 - Vital Signs

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."

During a physical assessment, the nurse should implement which actions initially when determining if a client's radial pulse is irregular? Select all that apply.

Assess the client's apical pulse for a full minute. Assess the client's S1 and S2 sounds for regularity.

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

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

During a general survey, the nurse asks if the patient is feeling cold. What did the nurse most likely observe in the patient?

The patient is wearing clothing that is inconsistent with warm weather.

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

assists the nurse in formulating appropriate subjective questioning

A client's blood pressure is affected by

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

The nurse is preparing to assess an adult client in the clinic. The nurse observes that the client is wearing lightweight clothing that is worn and soiled, although the temperature is below freezing outside. The nurse anticipates that the client may be

lacking adequate finances

The nurse is preparing to assess the respirations of an alert adult client. The nurse should:

observe for equal bilateral chest expansion of 2.54 to 5.08 cm (1 to 2 in).

What site for taking body temperature with a glass thermometer is contraindicated in patients who are unconscious?

oral

The current blood pressure measurement on a 24-hour uncomplicated postoperative patient 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

orthostatic hypotension

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?

18

During an initial assessment of a new patient, the nurse notes that the patient's weight is 210 lb and his height is 6'0". What is the patient's body mass index (BMI)?

28.5

A nurse assesses 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?

45-60

A client's blood pressure while lying supine is recorded as 124/76 mmHg. The nurse records the client's pulse pressure as which of the following?

48mmHg

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

97.4 F

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

98/52 mmHg

The nurse is beginning examination of the client. All the following areas are important to observe as part of the general survey except:

Blood 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?

Anxiety

Before assessing vital signs, the nurse knows that it is important to assess what?

Any medications the client is currently taking.

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

Auscultatory gap

The nurse is conducting an assessment of an older adult client who has a diagnosis of chronic heart failure. How can the nurse best assess the effects of the client's stroke volume?

Calculate the difference between the diastolic and systolic pressures.

An elderly client has an oral temperature of 96.3°F. Which action should the nurse take in regards to this reading?

Chart the finding and continue with the assessment.

Which technique demonstrates the proper position of the arm by a nurse when measuring a blood pressure?

Client sitting with arm outstretched and even with the heart

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

Deep in the posterior sublingual pocket

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; hair disheveled, no makeup, and will not make eye contact. Based on this data, which nursing diagnosis can the nurse confirm?

Depression

Body temperature is not impacted by which of the following factors?

Diet

Which of the following factors affect blood pressure? Select all that apply.

Ethnicity Smoking Weight Stress

The nurse is completing the assessment of a client who takes a beta-adrenergic blocker and a diuretic. Which assessment would be most important for the nurse to complete to ensure safety with a client receiving antihypertensive agents?

Evaluating for orthostatic hypotension

A client is wearing a hospital gown and sitting on the examination table. What area should the nurse include when completing the general survey?

Facial expression

The nurse is completing the general survey of a client and determines that the client's temperature is 102°F. Which of the following would the nurse also expect to find?

Heart rate greater than 100 bpm

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?

Isolated systolic hypertension

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

It occludes with moderate pressure.

When assessing an older adult client with osteoporotic thinning and vertebral collapse, which of the following findings would the nurse expect to identify?

Kyphosis

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

Not all of the heartbeats are reaching the periphery.

An older adult client has been admitted to the medical unit after suffering an exacerbation of chronic obstructive pulmonary disease (COPD). Which of the following should the nurse do to assess the depth of the client's respirations?

Observe the client's chest expansion bilaterally.

Assessment of the pulse amplitude is accomplished by which of the following?

Palpating the flow of blood through an artery

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

After teaching a group of students about blood pressure and Korotkoff's sounds, the instructor determines that the teaching was successful when the students identify which of the following?

Phase II sounds appear muddled and swishing.

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:

Record the vital signs

A patient recovering from abdominal surgery is complaining of pain. The nurse realizes that the patient is most likely experiencing which type of pain?

Somatic

A client comes to the clinic for a follow-up evaluation of his blood pressure. On two previous visits his values were 140/88 mmHg and 144/92 mmHg. Today, the client's blood pressure is 146/94 mmHg. The nurse would categorize this client's blood pressure as which of the following?

Stage 1 Hypertension

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

Stage 2 Hypertension

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

Stage 2 Hypertension

An 84-year-old man has been admitted to the emergency department from an extended care facility. Facility staff suspect that the client has pneumonia, and his malaise, productive cough, shortness of breath, and adventitious breath sounds are consistent with this diagnosis. However, the nurse's assessment of the client's vital signs yields an oral temperature of 97.5°F. How should the nurse best interpret this assessment finding?

The client's normothermic temperature does not rule out the presence of an infection.

A nurse is reviewing a colleague's documentation of a client assessment. The nurse reads that the client's radial pulse was 2+. How should the nurse interpret this assessment finding?

The client's radial pulse occluded with moderate pressure.

The nurse has begun a client's assessment and is applying the blood pressure cuff on a client's arm. Which action would be most appropriate?

The cuff is placed about 1 inch above the antecubital area.

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?

Tympanic