Chapter 19 Vital Signs

A patient has regular but abnormally rapid respirations of more than 24 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.

A nurse has been asked to measure the arterial oxygen saturation of a patient who has consumed organic phosphorus poison. While using the pulse oximeter with digital probes, what are the factors that affect the functional ability of the device? Select all that apply.

Nail polish, artificial nails, and metal studs in the nails interfere with light transmission of the device and yield inaccurate results. The presence of hypothermia at the assessment site interferes with the device functioning by decreasing the peripheral blood flow. Dark skin pigmentation results in device malfunction and may yield an overestimation of saturation.

A woman experiences a rise in body temperature during ovulation. Which hormone is responsible for a rise in body temperature during ovulation?

Ovulation is associated with the release of greater amounts of progesterone into circulation, which is responsible for raising body temperature. Inhibin, estrogen, and luteinizing hormone have no role in raising body temperature. Inhibin inhibits the synthesis and secretion of follicle-stimulating hormone. Estrogen is the female sex hormone responsible for development of secondary sexual characteristics in females and regulation of the menstrual cycle. Luteinizing hormone triggers the process of ovulation.

A 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 biceps and triceps muscles at the antecubital fossa. The radial pulse is located at the thumb side of forearm at wrist. This pulse is used to assess the circulation to hand. The ulnar pulse is located at the ulnar side of forearm at the wrist. This pulse is used to assess the circulatory status to the hand and also perform Allen's test. The apical pulse can be palpated at the fourth to fifth intercostals space at the left midclavicular line.

Which arterial site does a nurse choose to assess circulation to the lower arm and auscultate blood pressure?

The brachial site is suitable for assessing circulation in the lower arm and auscultating blood pressure. The ulnar site is used to assess circulation to the hand. The apical site is suitable for auscultating the apical impulse. The carotid site is easily accessible and is used during shock and cardiac arrest

The nurse is taking vital signs of a newborn. Which diastolic blood pressure finding is considered normal in a newborn?

The normal diastolic blood pressure for a newborn is between 20 and 60 mm Hg. Diastolic pressure of 53 mm Hg falls within this normal range. Diastolic pressure of 15 mm Hg falls below the normal level and thus indicates low blood pressure. A diastolic pressure of 80 mm Hg or 74 mm Hg is above the normal range and thus indicates high blood pressure.

What is a normal rectal temperature of an adult patient?

The normal rectal temperature range for an adult is 34.4° to 37.8°C; therefore, a temperature reading of 35.6°C is a normal finding in an adult. 33.1°C is below the normal range and indicates hypothermia; 38.2°C and 40.2°C are above the normal range and indicate hyperthermia.

A nurse is caring for a patient who has bradypnea. Bradypnea is said to be present when breathing is regular but abnormally slow, i.e. less than how many breaths per minute? Record your answer using a whole number. ____________

The normal respiratory rate for an adult is 12 to 20 breaths/min. Bradypnea is said to be present when breathing is regular and abnormally slow, i.e. less than 10 breaths/minute.

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

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.

Which part of the brain controls the patient's respiratory functions

Respiratory centers in the medulla and pons are stimulated by impulses from chemoreceptors located throughout the body. Broca's area is present in the frontal lobe and is associated with the production of speech. The cerebellum is located at the base of the brain above the brain stem. It coordinates the voluntary functions of the body such as posture, balance, and coordination. The hypothalamus is the part of brain below the thalamus that regulates body temperature.

A patient is advised an electrocardiogram to rule out dysrhythmia. Which statement is true about an electrocardiogram?

An electrocardiogram records the electrical activity of the heart for a 12-second interval. The procedure involves placing electrodes across the patient's chest followed by recording the heart rhythm. A Holter monitor is worn on the patient's body, and it records and stores 24 hours of electrical activity. The recorded information cannot be accessed before the 24 hours of assessment. A cardiac telemetry provides continuous monitoring of the heart transmitted to a stationary monitor. It records the heart activity in relation to the patient's activities. It has the advantage of allowing immediate treatment if the heart rate becomes unstable.

A nurse is assessing the respiratory pattern of a patient. Which statements are true about various patterns of respiration? Select all that apply.

Apnea is the cessation of breathing for a short period of time. Kussmaul's respiration is the increased rate and depth of breathing due to alterations in pH. Cheyne-Stokes' respiration is characterized by a period of apnea following a period of rapid and shallow breathing. This type is generally seen after injury to the brain stem or reduced flow of oxygenated blood to the brainstem.