Chapter 8: Assessing General Status and Vital Signs

Anxiety

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 will not make eye contact. Based on this data, which nursing diagnosis can the nurse confirm?

-the client just finished exercising -the client is ovulating - the client is stressed

A nurse assesses a female client's core body temperature and finds that she has a slightly elevated temperature. Which of the following factors could explain this finding? Select all that apply

-grimacing -holding a shoulder -shallow, rapid breathing

A nurse assessing a client's pain level while taking his blood pressure. Which of the following are signs of pain that the nurse should look for in the assessment? Select all that apply

Palate the carotid arteries

A nurse finds a radial pulse that is weak and thready. What action should the nurse take next?

120/55 mm Hg

A nurse has an order to obtain orthostatic blood pressure readings in a client admitted with dehydration. The sitting blood pressure is 140/75 mm Hg. Which blood pressure reading with the client standing should e nurse recognize as orthostatic hypotension?

-date and location of the client's last blood pressure check -onset and character of the client's chest pain -a list of all of the client's current medications

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

45-60

A nurse is assessing the pulse rate of an athletic client during a routine check up. The nurse should anticipate the pulse rate to be in what range of beats per minute ?

18

A nurse is assessing the respiratory rate o an elderly client. Which of the following findings in breaths per minute would indicate a normal respiratory rate in this client?

Temperate, pulse, respiration, and blood pressure

A nurse is preparing to assess a client's vital signs. In which order should the nurse assess them?

"Do you need to empty your bladder?"

A nurse measures a client's blood pressure and obtains a reading of 150/85 mm Hg. Which question should the nurse ask the client in regards to this reading?

Stage 2 hypertension

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

"Have you been sitting for a long time"

A nurse notes that the pulse rate of a client is less than 60 beats per minutes. Which question is appropriate for the nurse to ask the client in regards to this finding?

Marfan's syndrome

A nurse observes that a young mans arm appears to be greater than his height. Which condition should the nurse suspect in this client?

Parkinson's disease

A nurse observes the gait of an elderly client admitted for surgery. The client's gait is stiff with rigid movements. The nurse should ask this client questions about which disease?

Isolated systolic hypertension

A nurse obtains a blood pressure on an elderly client of 169/70 mm Hg. The nurse knows that the term for this condition is what?

Left arm

A nurse obtains a client's blood pressure (BP) on admission in both arms: right arm BP is 130/75 mm Hg and left arm BP is 140/80 mm Hg. Which arm should the nurse use for subsequent blood pressure reading?

Bradycardia

A nurse obtains a pulse rate on an adult client of 56 beats per minute. What is the correct term that the nurses should use to document this finding?

Chart the finding and continue with the assessment

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

Dressing self-care deficit

An elderly client is admitted with new onset of left-sided weakness, slurred speech, and hypotension. The client's husband states that she has stopped taking her blood pressure medications for the past week because they were making her feel dizzy and lacking in energy. High nursing diagnosis can be confirmed from this data?

To see the client before the client assumes a social face or behavior

Before calling a client back to an examination room, the nurse quickly observes the client in the waiting room from head to toe. Which of the following is best rationale for this action?

Chronic pulmonary obstructive disease

During the physical assessment of a client, a nurse observes that the client tends to lean forwards and brace himself with his arms. The nurse recognizes this as a sign of what disease process?

Palpating

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?

1+

The nurse assesses the amplitude of the client's radial pulse and finds it to be weak and diminished. Which of the following scores should the nurse record?

Watch chest movement before removing the stethoscope after counting the apical beat

The nurse is assessing a client's respiratory rate. Which of the following should the nurse do to ensure accuracy of this assessment?

Rigid

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?

Tympanic

The nurse recognizes that assessment of core body temperature is quick, noninvasive, and safe using which method?

Count the pulse for a full minute for an accurate rate

What action is appropriate for a nurse to perform when an irregular radial pulse is palpable on a client?

Ashen gray

Which abnormal skin color should a nurse anticipate assessing on a dark-skinned client?

Client sitting with arm slightly flexed and even with the heart

Which technique demonstrates the proper positioning of the client's arm by a nurse when measuring a blood pressure?