Vital Signs

25. A patient's blood pressure is 118/82. He asks the nurse to explain "what the numbers mean." The nurse's best reply would be: 1. "The numbers are within normal range and nothing to worry about." 2. "The bottom number is the diastolic pressure and reflects the stroke volume of the heart." 3. "The top number is the systolic blood pressure and reflects the pressure on the arteries when the heart contracts." 4. "The concept of blood pressure is difficult to understand. The main thing to be concerned about is the top number, or systolic blood pressure."

"The top number is the systolic blood pressure and reflects the pressure on the arteries when the heart contracts."

33. When auscultating the blood pressure of a 25-year-old, the nurse the phase I Korotkoff sounds begin at 200 mm Hg. At 100 mm Hg the Korotkoff sounds muffle. At 92 mm Hg the Korotkoff sounds disappear. How should the nurse record this patient's blood pressure? 1. 200/92 2. 200/100 3. 100/200/92 4. 200/100/92

200/92

32. The nurse has collected the following information on a patient: palpated blood pressure—180; auscultated blood pressure—170/100; apical pulse—60; radial pulse—70. What is the patient's pulse pressure? 1. 10 2. 70 3. 80 4. 100

70

27. A nurse is helping at a health fair at a local mall. When taking blood pressures on a variety of people, the nurse keeps in mind: 1. After menopause, blood pressure in women is usually lower than in men. 2. A black adult's blood pressure is usually higher than that of whites of the same age. 3. Blood pressure measurements in overweight people should be the same as those of normal weight. 4. A teen's blood pressure reading will be lower than that of an adult.

A black adult's blood pressure is usually higher than that of whites of the same age.

7. The nurse should measure rectal temperatures in which of the following patients? 1. A school-age child 2. An elderly adult 3. A comatose adult 4. A patient who is receiving oxygen by nasal cannula

A comatose adult

10. When assessing an older adult, the nurse keeps in mind that which vital sign changes occur with aging? 1. An increase in pulse rate 2. A widened pulse pressure 3. An increase in body temperature 4. A decrease in diastolic blood pressure

A widened pulse pressure

39. Which of the following statements is true regarding vital sign measurements in aging adults? 1. The pulse is more difficult to palpate because of the stiffness of the blood vessels. 2. An increased respiratory rate and a shallower inspiratory phase are expected findings. 3. A decreased pulse pressure occurs from changes in systolic and diastolic blood pressures. 4. Changes in the body's temperature regulatory mechanism leave the aging person more likely to develop a fever.

An increased respiratory rate and a shallower inspiratory phase are expected findings.

41. The nurse is performing a general survey. Which finding is considered normal? 1. When standing, the patient's base is narrow. 2. The patient appears older than his stated age. 3. Arm span (fingertip to fingertip) is greater than the height. 4. Arm span (fingertip to fingertip) equals height.

Arm span (fingertip to fingertip) equals height.

45. A 75-year-old man has a history of hypertension and was recently changed to a new antihypertensive drug. He reports feeling dizzy at times. How should the nurse evaluate his blood pressure? 1. Assess blood pressure and pulse in the supine, sitting, and standing positions. 2. Have Mr. Jones walk around the room and assess his blood pressure after activity. 3. Assess his blood pressure and pulse at the beginning and end of the examination. 4. Take the blood pressure on the right arm and then 5 minutes later take the blood pressure on the left arm.

Assess blood pressure and pulse in the supine, sitting, and standing positions

2. When measuring a patient's weight, the examiner keeps in mind which of the following? 1. Always weigh the patient with only his or her undergarments on. 2. It does not matter what type of scale is used, as long as the weights are similar from day to day. 3. The patient may leave on his or her jacket and shoes as long as this is documented next to the weight. 4. Attempt to weigh the patient at approximately the same time of day, if a sequence of weights is necessary.

Attempt to weigh the patient at approximately the same time of day, if a sequence of weights is necessary.

38. A 4-month-old child is at the clinic for a well-baby check-up and immunizations. Which of the following actions is most appropriate when the nurse is assessing an infant's vital signs? 1. Palpate the infant's radial pulse and note any fluctuations resulting from activity or exercise. 2. Auscultate an apical rate for 1 minute and assess for any normal irregularities, such as sinus arrhythmia. 3. Assess the infant's blood pressure by using a stethoscope with a large diaphragm piece to hear the soft muffled Korotkoff sounds. 4. Watch the infant's chest and count the respiratory rate for 1 minute because the respiratory pattern may vary significantly.

Auscultate an apical rate for 1 minute and assess for any normal irregularities, such as sinus arrhythmia.

24. The nurse is assessing the vital signs of a 3-year-old patient who appears to have an irregular respiratory pattern. How should the nurse assess this child's respirations? 1. Count the respirations for a full minute, noting rate and rhythm. 2. Check the child's pulse and respirations simultaneously for 30 seconds. 3. Check the child's respirations for a minimum of 5 minutes to identify any variations in respiratory pattern. 4. Count the patient's respirations for 15 seconds and multiply by four to obtain the number of respirations per minute.

Count the respirations for a full minute, noting rate and rhythm.

50. During an examination, the nurse notes that a female patient has a round "moon" face, central trunk obesity, and a cervical hump. Her skin is fragile with bruises. The nurse notes that the patient has which condition? 1. Marfan's syndrome 2. Gigantism 3. Cushing's syndrome 4. Acromegaly

Cushing's syndrome

20. When assessing a patient's pulse the nurse should note which of the following characteristics? 1. Force 2. Pallor 3. Capillary refill time 4. Timing in the cardiac cycle

Force

46. Which of the following specific measurements is the best index of a child's general health? 1. Vital signs 2. Height and weight 3. Head circumference 4. Chest circumference

Height and weight

36. Which of the following statements is true regarding thigh pressure? 1. Auscultate either the popliteal or femoral vessels to obtain a thigh pressure. 2. The best position to measure thigh pressure is the supine position with the knee slightly bent. 3. If the blood pressure in the arm is high in an adolescent, compare it with the thigh pressure. 4. The thigh pressure is lower than that in the arm due to distance away from the heart and the size of the popliteal vessels.

If the blood pressure in the arm is high in an adolescent, compare it with the thigh pressure.

31. The nurse is taking an initial blood pressure on a 72-year-old patient with documented hypertension. How should the nurse proceed? 1. Place the cuff on the patient's arm and inflate it 30 mm Hg above the patient's pulse rate. 2. Inflate the cuff to 200 mm Hg in an attempt to obtain the most accurate systolic reading. 3. Inflate the blood pressure cuff 30 mm Hg above the point at which the palpated pulse disappears. 4. Look at the patient's past blood pressure readings and inflate the cuff 30 mm Hg above the highest systolic reading recorded.

Inflate the blood pressure cuff 30 mm Hg above the point at which the palpated pulse disappears.

44. Which of the following best describes the concept of mean arterial pressure (MAP)? 1. MAP is the pressure of the arterial pulse. 2. MAP reflects the stroke volume of the heart. 3. It is the pressure forcing blood into the tissues, averaged over the cardiac cycle. 4. It is an average of the systolic and diastolic blood pressures and reflects tissue perfusion.

It is the pressure forcing blood into the tissues, averaged over the cardiac cycle

16. Which of the following describes the correct technique the nurse should use when assessing oral temperature with a mercury thermometer? 1. Wait 30 minutes if the patient has ingested hot or iced liquids. 2. Leave the thermometer in place 3 to 4 minutes if the patient is afebrile. 3. Place the thermometer in front of the tongue and have the patient close his or her lips. 4. Shake the mercury-in-glass thermometer down to 98° F before taking the temperature.

Leave the thermometer in place 3 to 4 minutes if the patient is afebrile.

26. Which of the following factors helps to determine blood pressure? 1. Pulse rate 2. Pulse pressure 3. Vascular output 4. Peripheral vascular resistance

Peripheral vascular resistance

3. A patient's weekly blood pressure readings for 2 months have ranged between 124/84 and 136/88 mm Hg, with an average reading of 126/86 mm Hg. The nurse knows that this blood pressure falls within which blood pressure category? 1. Normal blood pressure 2. Prehypertension 3. Stage I hypertension 4. Stage 2 hypertension

Prehypertension

11. Cellular metabolism requires a stable core temperature. This requires a balance between heat production and heat loss. Which of the following is a mechanism of heat loss in the body? 1. Exercise 2. Radiation 3. Metabolism 4. Food digestion

Radiation

34. A patient is being seen in the clinic for complaints of "fainting episodes that started last week." How should the nurse proceed with the examination? 1. Take his blood pressure in both arms and thighs. 2. Assist him to a lying position and begin taking his blood pressure. 3. Record his blood pressure in the lying, sitting, and standing positions. 4. Record his blood pressure in the lying and sitting positions and average these numbers to obtain a mean blood pressure.

Record his blood pressure in the lying, sitting, and standing positions.

47. When taking an axillary temperature, the nurse knows that which of the following statements is true? 1. A stable axillary temperature will register after 3 minutes. 2. The accuracy and reliability of this route is well established. 3. Its results are closer to core temperature than the inguinal site. 4. The axillary route is safer and more accessible than the rectal route.

The axillary route is safer and more accessible than the rectal route.

35. A 70-year-old man has a blood pressure of 150/90 in a lying position, 130/80 in a sitting position, and 100/60 in a standing position. How should the nurse evaluate these findings? 1. This is a normal response due to changes in the patient's position. 2. The change in blood pressure readings is called orthostatic hypotension. 3. The blood pressure reading in the lying position is within normal limits. 4. The change in blood pressure reading is considered within normal limits for the patient's age.

The change in blood pressure readings is called orthostatic hypotension.

42. Which of the following statements is true regarding measurement of blood pressure in children? 1. The blood pressure guidelines for children are based on age. 2. Phase II Korotkoff sounds are the best indicator of systolic blood pressure in children. 3. Use of Doppler device is recommended for accurate blood pressures until adolescence. 4. The disappearance of phase V Korotkoff can be used for the diastolic reading in children and adults.

The disappearance of phase V Korotkoff can be used for the diastolic reading in children and adults.

17. Which of the following statements is true regarding use of the tympanic thermometer? 1. A tympanic temperature is more time consuming than a rectal temperature. 2. The tympanic method is more invasive and uncomfortable than the oral method. 3. There is a reduced risk of cross-contamination compared with the rectal route. 4. The tympanic membrane most accurately reflects the temperature in the ophthalmic artery.

There is a reduced risk of cross-contamination compared with the rectal route.

6. When assessing an 80-year-old male patient, which of the following findings would be considered normal? 1. An increase in body weight from younger years 2. Additional deposits of fat on the thighs and lower legs 3. The presence of kyphosis and flexion in the knees and hips 4. A change in overall body proportion, a longer trunk, and shorter extremities

The presence of kyphosis and flexion in the knees and hips

43. What type of blood pressure measurement error is most likely to occur if the examiner does not check for the presence of an auscultatory gap? 1. The diastolic blood pressure may not be heard. 2. The diastolic blood pressure may be falsely low. 3. The systolic blood pressure may be falsely low. 4. The systolic blood pressure may be falsely high.

The systolic blood pressure may be falsely low.

49. When checking for proper blood pressure cuff size, the nurse knows that which of the following is true? 1. The standard cuff size is appropriate for all sizes. 2. The length of the rubber bladder should equal 80% of the person's arm circumference. 3. The width of the rubber bladder should equal 80% of the arm circumference. 4. The width of the rubber bladder should equal 40% of the arm circumference.

The width of the rubber bladder should equal 40% of the arm circumference.

23. The nurse is assessing the vital signs of a 20-year-old marathon runner and documents the following vital signs: temperature—97 F; pulse—50 beats per minute; respirations—14/minute; blood pressure—104/68 mm Hg. Which of the following statements is true about these results? 1. The patient is experiencing tachycardia. 2. These are normal vital signs for a healthy, athletic adult. 3. The patient's pulse rate is not normal—his physician should be notified. 4. On the basis of today's readings, the patient should return to the clinic in 1 week.

These are normal vital signs for a healthy, athletic adult.

29. A student is late for his appointment and has rushed across campus to the health clinic. Before assessing his vital signs, the nurse should: 1. allow him time to relax and rest 5 minutes before checking his vital signs. 2. check the blood pressure in both arms, expecting a difference in the readings because of his recent exercise. 3. monitor his vital signs immediately on his arrival at the clinic, then 5 minutes later, and note any differences. 4. check his blood pressure in the supine position because this will give a more accurate reading and allow him to relax at the same time.

allow him time to relax and rest 5 minutes before checking his vital signs.

8. The nurse is preparing to measure the length, weight, chest, and head circumference of a 6-month-old infant. The nurse would measure the infant's: 1. length by using a tape measure. 2. weight by placing him on an electronic standing scale. 3. chest circumference at the nipple line with a tape measure. 4. head circumference by wrapping the tape measure over the nose and cheekbones.

chest circumference at the nipple line with a tape measure.

5. A 1-month-old infant has a head measurement of 34 cm and has a chest circumference of 32 cm. The nurse would: 1. refer the infant to a physician for further evaluation. 2. consider this a normal finding for a 1-month-old infant. 3. expect the chest circumference to be greater than the head circumference. 4. ask the parent to return in 2 weeks to re-evaluate the head and chest circumferences.

consider this a normal finding for a 1-month-old infant.

21. When assessing the pulse of a 6-year-old boy, the nurse notes that his heart rate varies with his respiratory cycle, speeding up at the peak of inspiration and slowing to normal with expiration. The nurse would: 1. notify the physician immediately. 2. consider this a normal finding in children and young adults. 3. check the child's blood pressure and note any variation with respiration. 4. document that this child has bradycardia and continue with the assessment.

consider this a normal finding in children and young adults.

30. The nurse will perform a palpated pressure before auscultating blood pressure. The reason for this is to: 1. hear the Korotkoff sounds more clearly. 2. detect the presence of an auscultatory gap. 3. avoid missing a falsely elevated blood pressure. 4. identify phase IV of the Korotkoff sounds more readily.

detect the presence of an auscultatory gap.

4. Physical growth is the best index of a child's: 1. general health. 2. genetic makeup. 3. nutritional status. 4. activity and exercise patterns.

general health.

22. Which is true regarding the force, or strength, of the pulse? It: 1. is usually recorded on a 0- to 2-point scale. 2. demonstrates elasticity of the vessel wall. 3. is a reflection of the heart's stroke volume. 4. reflects the blood volume in the arteries during diastole.

is a reflection of the heart's stroke volume.

13. When evaluating the temperature of older adults, the nurse remembers that an older adult's body temperature: 1. is lower than that of younger adults. 2. is about the same as that of a young child. 3. depends on the type of thermometer used. 4. varies widely because of less effective heat control mechanisms.

is lower than that of younger adults.

9. The nurse knows that one advantage of the tympanic thermometer is that: 1. its rapid measurement is useful for uncooperative younger children. 2. it is the most accurate method for measuring temperature in newborn infants. 3. it is an inexpensive means of measuring temperature. 4. studies strongly support use of the tympanic route in children under age 6 years.

its rapid measurement is useful for uncooperative younger children.

37. The nurse is preparing to measure the vital signs of a 6-month-old infant. The nurse will: 1. measure respirations and then pulse and temperature. 2. measure vital signs more frequently than in an adult. 3. explain procedures and encourage the infant to handle the equipment. 4. allow the infant to become familiar with the nurse by performing the physical examination first and then measuring the vital signs.

measure respirations and then pulse and temperature.

1. When performing a general survey, the examiner is: 1. observing the patient's body stature and nutritional status. 2. interpreting the subjective information the patient has reported. 3. measuring the patient's temperature, pulse, respirations, and blood pressure. 4. observing specific body systems while performing the physical assessment.

observing the patient's body stature and nutritional status.

40. In a patient with acromegaly, the nurse will expect to observe: 1. heavy, flattened facial features. 2. growth retardation and a delayed onset of puberty. 3. overgrowth of bone in the face, head, hands, and feet. 4. increased height and weight and delayed sexual development.

overgrowth of bone in the face, head, hands, and feet.

19. When assessing the radial pulse of a patient, the nurse should count the: 1. pulse for 1 minute if the rhythm is irregular. 2. pulse for 15 seconds and multiply by four, if the rhythm is regular. 3. initial pulse for a full 2 minutes to detect any variation in amplitude. 4. pulse for 10 seconds and multiply by six, if the patient has no history of cardiac abnormalities.

pulse for 1 minute if the rhythm is irregular

15. When assessing a 75-year-old patient who has asthma, the nurse notes that he assumes a tripod position, leaning forward with arms braced on the chair. On the basis of this observation, the nurse would: 1. assume that the patient is eager and interested in participating in the interview. 2. evaluate the patient for abdominal pain, which may be exacerbated in the sitting position. 3. assume that the patient is having difficulty breathing and assist him to a supine position. 4. recognize that a tripod position is often used when a patient is having respiratory difficulties.

recognize that a tripod position is often used when a patient is having respiratory difficulties.

12. When measuring a patient's body temperature, the nurse keeps in mind that body temperature is influenced by: 1. constipation. 2. patient's emotional state. 3. the diurnal cycle. 4. the nocturnal cycle.

the diurnal cycle.

14. A 60-year-old male patient has been treated for pneumonia for the past 6 weeks. He is seen today in the clinic for an "unexplained" weight loss of 10 pounds over the last 6 weeks. The nurse knows that: 1. his weight loss is probably from unhealthy eating habits. 2. chronic diseases such as hypertension cause weight loss. 3. unexplained weight loss often accompanies short-term illnesses. 4. his weight loss is probably the result of a mental health dysfunction.

unexplained weight loss often accompanies short-term illnesses.

18. To accurately assess a rectal temperature on an adult, the nurse would: 1. use a lubricated blunt tip thermometer. 2. insert the thermometer 2 to 3 inches into the rectum. 3. leave the thermometer in place up to 8 minutes if the patient is febrile. 4. wait 2 to 3 minutes if the patient has recently smoked a cigarette.

use a lubricated blunt tip thermometer.

48. When counting an infant's respirations, the nurse will: 1. watch the chest rise and fall. 2. watch the abdomen for movement. 3. place a hand across the infant's chest. 4. use a stethoscope to listen to the breath sounds.

watch the abdomen for movement.

28. The nurse notices a colleague is preparing to check the blood pressure of an obese patient by using a standard-sized blood pressure cuff. The nurse should expect the reading to: 1. yield a falsely low blood pressure. 2. yield a falsely high blood pressure. 3. be the same regardless of cuff size. 4. vary as a result of the technique of the person performing the assessment.

yield a falsely high blood pressure.