Chapter 24 Vital Signs

A client admitted with dehydration reports feeling dizzy with ambulation. What teaching would the nurse provide to the client?

"Dizziness when you change position can occur when fluid volume in the body is decreased."

A client has had a left-side mastectomy. How does this affect the blood pressure assessment?

Assessment of blood pressure is impeded.

When assessing blood pressure using a Doppler ultrasound, what technique by the nurse would obtain the best reading?

Center the bladder of the cuff over the artery, lining up the artery marker on the cuff with the artery itself.

An ultrasonic Doppler is used for:

auscultating a pulse that is difficult to palpate.

The client's blood pressure has gradually decreased in the last 2 days. Which condition would cause this change?

the client who has had persistent diarrhea Vital signs—body temperature (T), pulse (P), respirations (R), and blood pressure (BP)—indicate the function of some of the body's homeostatic mechanisms. Measurement and interpretation of the vital signs are important components of assessment that can yield information about underlying health status.

Based upon circadian rhythms, when would the nurse note the highest temperature during a 24-hour period?

1700 (Body temperature fluctuates throughout the day. Temperature is usually lowest around 0300 and highest from 1700 to1900.)

A nurse is assessing the respiratory rate of a sleeping infant. What would the nurse document as a normal finding?

30 to 60 breaths per minute

A nurse is calculating the cardiac output of an adult with a stroke volume of 75 mL (75 × 109/L) and a pulse of 78 beats/min. What number would the nurse document for this assessment?

5,850 mL (5,850 × 109/L)

The nurse is performing a telephone follow-up with parents whom she taught to monitor their newborn's BP and pulse at home. Which results reported by the parents would indicate that the parents are performing the technique correctly and there is no cause for concern?

80/50 mm Hg and 145 bpm

The normal adult temperature obtained through the oral route ranges from:

97.6°F to 99.6°F (36.4°C to 37.6°C)

The nurse is preparing to measure a client's rectal temperature. Which supplies and equipment should the nurse have available before beginning the procedure? Select all that apply.

An electronic thermometer with a rectal probe Disposable probe cover Water-soluble lubricating gel

A client is taking medications to treat a heart dysrhythmia. Which site should be used to assess the pulse in this client?

Apical

The nurse is preparing to measure an adult's radial pulse using a Doppler device. Arrange the following steps of the procedure in the correct order.

Apply conducting gel to the site where the pulse will be auscultated. Place the Doppler probe tip in the gel. Adjust the volume of the device, as needed. Maneuver the tip of the Doppler probe over the area until the pulse is heard. Count the number of heartbeats for 1 full minute. Wipe the gel off of the client's skin.

The nurse is talking to an older adult client who performs home blood pressure monitoring (HBPM) and finds that recently her BP measurements have consistently been low. Which factors may contribute to causing this client's BP to be falsely decreased? Select all that apply.

Applying too wide a cuff Releasing the valve rapidly Using cracked or kinked tubing

The client is self-monitoring blood pressure at home and reports that every reading is 150/90 mm Hg. What is the priority nursing intervention?

Ask the client to demonstrate self-blood pressure assessment. While all of these interventions would be appropriate if the client is hypertensive, it is important to assess whether the client is measuring their BP correctly before assuming that hypertension is present. It would be very rare to have a BP of the exact same measurement with every assessment. Therefore, providing the client with a larger blood pressure cuff, recommending lower sodium in the client's diet, and reporting the readings to the primary care provider are not priority actions at this time.

The nurse is assessing a client's blood pressure and is having difficulty hearing Korotkoff sounds. What is the most appropriate nursing action?

Ask the client to make a fist after cuff inflation. Korotkoff sounds result from the vibrations of blood within the arterial wall and changes in blood flow. These sounds occur in phases and correlate with blood pressure measurement. They can be increased by asking the client to make a fist after cuff inflation. Standing for BP assessment is not appropriate, as blood volume changes. Waiting to assess the BP could be problematic if the client is experiencing low BP or an acute change. Contacting the PCP is not appropriate, as there is further nursing action that can be taken.

A nurse attempts to count the respiratory rate for a client via inspection and finds that the client is breathing at such a shallow rate that it cannot be counted. What is an alternative method of determining the respiratory rate for this client?

Auscultate lung sounds, count respirations for 30 seconds, and multiply by 2.

An obese client has developed peripheral edema as a consequence of heart failure, making it very difficult for the student nurse to accurately palpate the client's peripheral pulses. How should the nurse proceed with this assessment?

Auscultate the client's apical pulse.

A nurse is assessing the respirations of a 60-year-old female client and finds that the client's breaths are so shallow that the respirations cannot be counted. What would be the appropriate initial nursing intervention in this situation?

Auscultate the lung sounds and count respirations.

Which peripheral pulse site is generally used in emergency situations?

Carotid The carotid artery is lightly palpated to obtain a pulse in emergency assessments, such as in a client in shock or cardiac arrest. The brachial pulse site is used for infants who have had a cardiac arrest. The apical pulse is the fifth intercostal space for adults and the fourth intercostal space for a young child or infant. Using a stethoscope at the apex of the heart, a nurse can assess the lub dub of the heart sounds. Radial pulse is too distant to assess a pulse in an emergency assessment. Temporal pulse is difficult to assess.

A nurse is taking a blood pressure measurement to assess for orthostatic hypotension in a client. Which signs and symptoms will the nurse assess related to this condition? Select all that apply.

Client reports feeling dizzy when sitting up from a supine position. Client reports feeling palpitations when rising from a supine to a standing position. The client states, "I feel lightheaded when sitting up."

Which is not a characteristic used to describe the pulse?

Depth

The body loses heat continually through several different processes. Which process is an example of how heat is lost through evaporation?

Diaphoresis Evaporation causes heat loss as water is transformed to gas. An example of this is diaphoresis, or sweating.

The nurse is assessing the pulse amplitude for a client. Documentation by the nurse states, "Pulses are +1 in the lower left extremity". What amplitutde is the nurse assessing?

Diminished, weaker than expected A +1 pulse amplitude indicates that the pulse is diminished and weaker than expected. An absent pulse is a 0. A pulse that is brisk is a +2 and a bounding pulse is +3.

A nurse is caring for a client with orthostatic hypotension. What are symptoms of orthostatic hypotension? Select all that apply.

Dizziness Syncope-temporary loss of consciousness Nausea Weakness

Which describes diastolic blood pressure?

During ventricular relaxation, blood pressure is due to elastic recoil of the vessels. Diastolic blood pressure occurs when ventricular relaxation happens, and blood pressure is due to elastic recoil of the vessels. Systolic blood pressure is measured during ventricular contraction. Systolic blood pressure is highest when the ventricles of the heart eject blood into the aorta and pulmonary arteries. Blood pressure in general is measured by taking the flow of blood produced by contractions of the heart and multiplying it by the resistance to blood flow through the vessels (P = F × R).

A client has smoked most of his life and has labored respirations. He is experiencing:

Dyspnea describes respirations that require excessive effort.

A nurse is caring for a client with orthostatic hypotension. Which nursing interventions are appropriate to decrease the risk of falls? Select all that apply.

Encourage oral fluid intake. Encourage slow movement from the bed to the chair. Encourage the client to use the call light prior to getting out of bed. Encourage the use of the call light for help to the bathroom.

A client informs the nurse that a mercury thermometer is used at home to take the temperature of her children when they are sick. What health education by the nurse is most appropriate?

Encourage the client to use an alternative type of thermometer to assess temperature in the home.

When creating the teaching plan for a client who will be monitoring his or her pulse at home, which factors should the nurse teach the client that may influence the pulse rate by causing an increase in pulse? Select all that apply.

Exercise Fever Stress

The nurse is performing bilateral comparison of pulse sites for strength and quality instead of counting the beats per minute. Which pulse locations will the nurse palpate to gather this assessment data? Select all that apply.

Femoral Dorsalis pedis Popliteal Posterior tibial

Which pathologic condition would result in release of antidiuretic hormone (ADH) by the posterior pituitary?

Hemorrhage

The temperature is 102°F (39°C) during a heat wave. The nurse can expect admissions to the emergency room to present with:

Increased Temperature

Upon assessing a client who is hemorrhaging, the nurse is most likely to assess which compensatory change in vital signs?

Increased pulse rate When the stroke volume decreases, such as when blood volume is decreased because of hemorrhage, the heart rate increases to try to maintain the same cardiac output. Respirations may increase but the primary response is the increase in the heart rate. The blood pressure would decrease. Temperature is not affect initially in hemorrhage.

The nurse identifies the auscultatory gap while taking the client's blood pressure. What should the nurse do next?

Inflate the cuff about 30 mm Hg above the auscultatory gap.

A nursing student is manually taking the client's blood pressure. Which step will demonstrate the correct way of inflating the blood pressure cuff?

Inflate the cuff to 30 mm Hg above reading where brachial pulse disappeared.

A client monitoring his BP at home notices that his BP is higher in one arm than the other. He calls his health care provider for guidance. What is the most appropriate information for the nurse to give this client?

It has been found that most people have differences in BP between arms and that he should use the arm that gives him the highest reading for accurate results.

The nurse is assessing the apical pulse of a client using auscultation. What action would the nurse perform after placing the diaphragm over the apex of the heart?

Listen for heart sounds.

A nurse can most accurately assess a client's heart rate and rhythm by which of the following methods?

Listen with the stethoscope at the fifth intercostal space left mid-clavicular line.

A nurse documents the following assessment for an infant: temperature 98.9°F (37.2°C), pulse 90 bpm, respirations 35 bpm, and blood pressure 85/73. What is the next appropriate action of the nurse based on these assessments?

No action is needed; these are normal assessments.

A nurse needs to measure the blood pressure of a client with an electronic manometer. Which of the following advantages does an electronic manometer provide over an aneroid manometer or mercury manometer?

No stethoscope is required.

During a busy shift, Nurse R. admitted a postoperative client who is obese. Nurse R. used the standard size of blood pressure cuff available on the unit, despite the fact that the client's upper arms have a large circumference. What are the potential consequences of Nurse R.'s action?

Nurse R. may obtain a blood pressure reading that is higher than the actual blood pressure.

The nurse places a client experiencing labored breathing in an upright position. The nurse notes that the client is able to breathe more easily in this upright position and documents this condition on the chart as:

Orthopnea

A nurse is taking the vital signs of a 9-year old child who is anxious about the procedures. Which nursing action would be appropriate when assessing this child?

Perform the blood pressure measurement last.

Nurse T. has auscultated Mr. Weinstein's apical pulse while a colleague simultaneously palpated his radial pulse. This assessment of Mr. Weinstein's apical-radial pulse indicates that the two values differ significantly, a finding that suggests which health problem?

Peripheral vascular disease

A nurse is assessing the blood pressure of an adult client using the Korotkoff sounds technique to document the measurement. Which phase of Korotkoff sounds will the nurse use to document blood pressure measurements in the client?

Phase IV Phase IV sounds are muffled and have a blowing quality. The sound change results from a loss in the transmission of pressure from the deflating cuff to the artery. The point at which the sound becomes muffled is considered the first diastolic pressure measurement. K-1 (Phase 1): The appearance of the clear "tapping" sounds as the cuff is gradually deflated. The first clear "tapping" sound is defined as the systolic pressure. K-2 (Phase 2): The sounds in K-2 become softer and longer and are characterized by a swishing sound since the blood flow in the artery increases. K-3 (Phase 3): The sounds become crisper and louder in K-3 which is similar to the sounds heard in K-1. K-4 (Phase 4): As the blood flow starts to become less turbulent in the artery, the sounds in K-4 are muffled and softer. Some nurses record diastolic during Phase 4 and Phase 5. K-5 (Phase 5): In K-5, the sounds disappear completely since the blood flow through the artery has returned to normal. The last audible sound is defined as the diastolic pressure.

The nurse is preparing to assess a rectal temperature on an adult client. What is the appropriate nursing intervention?

Provide privacy for the client.

A nurse is assessing the pulse volume of a client with influenza. The nurse notes that the client has a thready pulse. Which of the following is a description of a thready pulse?

Pulse is felt with difficulty and disappears with slight pressure.

Which term indicates a potentially serious client condition?

Pyrexia, means an increase above normal in body temperature. Pulse pressure is an objective term related to the pulse. Eupnea means a normal breathing pattern. Afebrile means that the body temperature is not elevated.

The nurse is obtaining blood pressures for a group of assigned clients. Which technique accurately reflects a recommended guideline when assessing blood pressure?

Raise the client's arm over the head to help relieve congestion of blood in the limb and make the sounds louder and more distinct.

The nurse is providing discharge education for a client diagnosed with hypertension. Which teaching points about monitoring blood pressure should the nurse include in the plan? Select all that apply.

Recommend taking the blood pressure every day at the same time. Recommend a cuff size appropriate for the client's limb size. If using a forearm monitor, tell the client to keep wrist at heart level when using it.

The nurse is taking a rectal temperature on a client who reports feeling lightheaded during the procedure. What would be the nurse's priority action in this situation?

Remove the thermometer and assess the blood pressure and heart rate.

Infants and children's pulses vary most with:

Respirations The heart rhythm in infants and children varies markedly with respiration, increasing during inspiration and decreasing with expiration.

What instructions should be provided to a newly diagnosed hypertensive client about home blood pressure monitoring? Select all that apply.

Rest 3 to 5 minutes before taking your BP. Take three measurements and average together. Use a validated monitor with an automatic inflation cuff.

It is very important to assess for the quality of someone's respirations as well as describe what is heard with auscultation. Which describes stridor?

STRIDOR is a harsh, inspiratory sound that may be compared to crowing. It can indicate an upper airway obstruction. A high-pitched musical sound describes wheezing. Dyspnea is a term used to describe expirations that require excessive effort. Crackles are discontinuous popping sounds.

Which statement is true regarding the autonomic nervous system and its effect on the rate of a person's pulse?

Sympathetic nervous system activation occurs in response to a variety of stimuli, including changes in intravascular volume.

A client with newly diagnosed hypertension on BP medication has been taking her own BP at home for 2 weeks. When she calls and reports her BP readings to the nurse, the nurse notes an elevated BP in the morning. The client states that she wakes up, has her daily cup of coffee, and takes her BP before eating as she was instructed. What should the nurse recommend to this client?

Take her BP before drinking her morning cup of coffee.

The nurse is teaching a client how to take a daily blood pressure reading at home. The nurse includes instructions about obtaining an accurate blood pressure measurement. What additional information would the nurse include? Select all that apply.

Take your blood pressure every day prior to eating breakfast." "Rest 3 to 5 minutes before taking your blood pressure." "Keep both feet flat on the ground; do not cross your legs." "Place your arm on a table that is level with your heart."

The nurse observes the client's frequent use of the incentive spirometer. The client states "I do not want to have pneumonia while in the hospital." Which vital sign reading demonstrates effectiveness of this intervention?

Temperature of 98.2°F (36.7°C)

The nurse is obtaining vital signs for a client and assesses a heart rate of 124 beats per minute. What additional assessment information would be important to obtain that would explain the tachycardia? Select all that apply.

The client has reports of pain of 8 on a scale of 0 to 10 The client just finished ambulating with physical therapy The client has a temperature of 101.8°F (38.8°C)

The nurse is obtaining vital signs for a client and assesses a heart rate of 124 beats per minute. What additional assessment information would be important to obtain that would explain the tachycardia?

The client has reports of pain of 8 on a scale of 0-10 The client just finished ambulating with physical therapy The client has a temperature of 101.8 degrees Fahrenheit

When administering beta blocker medications, the physician adds an order to hold medication when the client is bradycardic. Which statement explains this order?

The client's pulse rate is below 60 beats per minute.

The nurse is assessing a new client's blood pressure using a manual sphygmomanometer. Which sound constitutes the client's systolic blood pressure?

The first appearance of faint but distinctive tapping sounds

The nurse is assessing a client's brachial artery blood pressure. Which nursing actions are performed correctly? Select all that apply.

The nurse centers the bladder of the cuff over the brachial artery about midway on the arm. The nurse notes the point on the gauge at which the first faint but clear sound appears, and increases in intensity as the diastolic pressure. The nurse repeats any suspicious reading before 1 minute has passed since the last reading. The nurse has the client lying or sitting down with the forearm supported at the level of the heart and the palm of the hand upward. The nurse wraps the cuff around the arm smoothly and snugly and fastens it.

The nurse is assessing the blood pressure of a hospitalized client using a Doppler ultrasound device. Which actions are performed correctly? Select all that apply.

The nurse places the client in a comfortable lying or sitting position. The nurse centers the bladder of the cuff over the artery, lining the artery marker on the cuff up with the artery. The nurse wraps the cuff around the limb smoothly and snugly and fastens it. The nurse checks that the needle on the aneroid gauge is within the zero mark.

The nurse is teaching the parents of an infant with an irregular heartbeat how to check the pulse rate. The infant's pulse is very high and irregular. What will the nurse have to do in order to teach these parents how to monitor their infant's pulse rate?

The parents will have to be taught how to use a stethoscope so that they can listen to and count the infant's apical pulse

A nurse is explaining to a nursing student why blood pressure is a frequently used assessment parameter in a wide variety of care settings. What can be inferred from an assessment of a client's blood pressure?

The resistance that the client's heart must overcome when pumping blood Blood pressure is representative of the amount of resistance that the heart must overcome in order to pump blood; increased BP equates with increased resistance, or afterload. Blood pressure is not necessarily indicative of oxygen supply, the relative volumes of the venous and arterial systems or the size of the heart.

Which client's blood pressure best describes the condition called hypotension?

The systolic reading is below 100 and diastolic reading is below 60.

A nurse is assessing the blood pressure of a client using the Korotkoff sound technique. The nurse notes that the phase I sound disappears for 2 seconds. What should the nurse document on the progress record?

There is an auscultatory gap. An auscultatory gap is a period during which sound disappears. An auscultatory gap can range as much as 40 mm Hg. A widening in the diameter of the artery takes place in the phase II of the Korotkoff sound technique. An adult diastolic pressure takes place in the phase IV of the Korotkoff sound technique.

When assessing a client's pulse, the nurse is able to palpate the pulse for some time before losing it upon exerting a little bit more pressure. The pulse is beating at 80 bpm. Which of these should the nurse document as the character of the client's pulse?

Thready pulse A feeble, weak, or thready pulse describes a pulse that is difficult to feel or, once felt, is obliterated easily with slight pressure. A normal pulse is described as strong when it can be felt with mild pressure over the artery. A pulse is considered rapid when the beats exceed 100 bpm, which is not the case here. A bounding or full pulse produces a pronounced pulsation that does not easily disappear with pressure. A strong pulse is felt with a very mild pressure over the artery.

A 62-year-old female client being treated for hypertension did not take her daily BP medication over the weekend because she was out of medication and the pharmacy was closed. Her average home blood pressure monitoring (HBPM) reading has been 130/82. Today her BP has been 138/90, 135/85, and 142/86. She calls the on-call nurse for her health care provider. What is the most appropriate thing for this nurse to advise this client?

To take the recommended daily dose of medication and call the health care provider if the average of her HBPM readings increase/decrease by 10, or if she has any other concerns.

The student nurse is having difficulty feeling the pedal pulse of the client with a fractured leg. What should the nurse do next?

Use the Doppler ultrasound device.

The student nurse is having difficulty feeling the pedal pulse of the client with a fractured leg. What should the nurse do next?

Use the Doppler ultrasound device. Peripheral pulses that cannot be detected by palpation may be assessed with an ultrasonic Doppler device. A conductive gel is first applied to the skin to reduce resistance to sound transmission. The transmitter of the device is then placed over the artery to be assessed. High-frequency waves directed at the artery from the transmitter are disturbed by the pulsating flow of blood and are reflected back to the ultrasound device. The sound disturbances (Doppler shifts) are amplified and heard through earpieces or a speaker attached to the device. The bell effect is created by light pressure on the stethoscope. Using the bell will not facilitate palpation but an auditory assessment. The nursing student should be familiar with other assessment devices such as the Doppler and not asking another nursing student to assess. Connecting the client to the oxygen saturation device does not assist in the assessment of pedal pulses.

A nurse is assessing clients in the emergency department for body temperature. Which nursing actions reflect proper technique when assessing body temperature by various methods? Select all that apply.

When assessing an oral temperature with an electronic thermometer, place the probe beneath the client's tongue in the posterior sublingual pocket. When assessing rectal temperature with an electronic thermometer, lubricate about 1 in (2.5 cm) of the probe with a water-soluble lubricant. When assessing temperature with an electronic thermometer, hold the thermometer in place in the assessment site until a beep is heard.

A 70-year-old client is taking his own pulse at home. He is following the instructions provided by the nurse. He counts his pulse 62 times in one minute. What should he do next?

Write it down Explanation: This pulse falls within a normal range for an older adult male, 40 to 100 beats per minute. He should document his pulse rate. There is not enough information provided to assume anything other than a normal pulse rate for age; therefore, there is no need to retake it or call the health care provider

Which client would the nurse consider at risk for low blood pressure?

a client with low blood volume

Which factor is not known to cause false blood pressure readings?

being in a warm environment

A nurse is caring for four adult clients. Which client would the nurse assess first?

client with a respiratory rate 32/min

A nurse is assessing an apical pulse on a cardiac client. The client is taking digoxin, which is a cardiac medication. The nurse can anticipate that the digoxin will:

decrease the apical pulse.

The nurse is preparing to assess a client's oral temperature. The nurse should plan to place the thermometer probe in which area of the client's mouth?

deep in the posterior sublingual pocket

The nurse understands that accurate blood pressure taking is dependent on several factors. Which example will most likely render an accurate blood pressure reading?

elevating the client's arm at heart level

The nurse knows that a client who is being taught to perform home blood pressure monitoring (HBPM) understands the teaching plan when he makes which statement about the size of the BP cuff? The cuff should:

fit snug around the upper arm with room to slip a fingertip under the cuff and should be 1 in (2.5 cm) above the crease of the elbow.

The nurse is assessing a client's brachial artery blood pressure. Which nursing actions are performed correctly? Select all that apply.

he nurse centers the bladder of the cuff over the brachial artery about midway on the arm. The nurse has the client lying or sitting down with the forearm supported at the level of the heart and the palm of the hand upward. The nurse wraps the cuff around the arm smoothly and snugly and fastens it.

A client presents to the Emergency Department with a temperature of 100.6F (38.1°C) and BP of 108/60 mm Hg. What intervention does the nurse anticipate providing?

oral fluids

Assessment of the pulse amplitude is accomplished by:

palpating the flow of blood through an artery.

Which outcome best reflects achievement of the goal, "The client will demonstrate correct steps in taking his own pulse rate"?

palpation of the radial pulse on the thumb side of the inner aspect of the wrist.

A client has an axillary temperature of 102.6 F (39.2°C). Which clinical manifestations would the nurse anticipate? (Select all that apply.)

respiratory rate 30/min headache red or flushed skin

The nurse is taking the client's temperature. The nurse understands that the rectal route is one of the most reliable. Which client can safely handle the rectal route of taking temperature?

the 65-year old male who just finished drinking coffee Hot or cold drinks may cause variations in oral temperature readings. Diaphoresis or air blowing over the face may affect temporal artery measurements; stool in the rectum can affect rectal temperatures.

A pulse deficit is the difference between:

the apical pulse and the radial pulse rates.