Chapter 8: Assessing General Status and Vital Signs

During the first assessment of the client, the nurse assesses the blood pressure in both arms. Which of the following findings is an acceptable variation?

118/78 mm Hg in the right arm and 122/80 mm Hg in the left arm Explanation: Usually, there is a difference in pressure of 5 mm Hg and sometimes up to 10 mm Hg between arms. Pressure difference of more than 10 to 15 mm Hg between arms suggests arterial compression or obstruction on the side with the lower pressure.

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

Ashen gray Explanation: The skin of a dark-skinned client with cyanosis would be ashen gray. The skin tone would appear yellowish in a light-skinned client if the client had jaundice. A beige-pink skin tone would be a normal finding for the light-skinned client. A reddish skin tone could be related to fever, sunburn, or infection.

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

120/55 mm Hg Explanation: A drop in both the systolic and diastolic readings of 20 mm Hg or more from the sitting position to the standing position indicates orthostatic hypotension. A drop of less than 20 mm Hg from the sitting position is considered normal. An elevation is not called hypotension but hypertension.

The nurse is admitting an elderly client with a diagnosis of congestive heart failure. Admission vital signs are respirations 38; pulse 172; blood pressure 86/72. How should the nurse best respond?

Notify the rapid response team Explanation: The client is in distress. The most appropriate action of the nurse is to notify the rapid response team. The nurse cannot administer IV fluids or medications without an order Reassessing in one hour is not an appropriate action due to the client's condition.

A nurse is caring for a patient who is ambulating for the first time after surgery. Upon standing, the patient complains of dizziness and faintness. The patient's blood pressure is 90/50. What is the name for this condition?

Orthostatic hypotension Explanation: Orthostatic hypotension (postural hypotension) is a low blood pressure associated with weakness or fainting when one rises to an erect position (from supine to sitting, supine to standing, or sitting to standing). It is the result of peripheral vasodilation without a compensatory rise in cardiac output.

A nurse is filling out an incident report after an older adult patient fell while attempting to transfer from her bed to a commode. Which of the following health problems should the nurse consider when patient falls occur?

Orthostatic hypotension Explanation: Orthostatic hypotension is associated with weakness or fainting when one rises to an erect position. Hypertension and dyspnea do not typically result in loss of balance and/or consciousness.

The nurse places the following device on a client's finger. What information is this device providing to the nurse?

Oxygen saturation Explanation: Oxygen saturation is the percentage to which hemoglobin is filled with oxygen. Pulse oximetry is a noninvasive technique to measure oxygen saturation of arterial blood. This device is not used to measure pulse, temperature, or respiratory rate.

A client's radial artery pulse rate is 42 beats in 30 seconds with occasional pauses. What action should the nurse take?

auscultate the heart rate for a full minute Explanation: If the radial pulse is irregular, the apical heart rate should be auscultated for a full minute. There is no need to palpate the carotid artery. Documenting that the pulse is 84 and irregular cannot be validated unless the heart rate is auscultated for a full minute. Palpating the radial pulse for a full minute will not necessarily provide the client's correct pulse rate since pauses are occurring.

Which of the following is an average normal temperature in centigrade for a healthy adult?

oral: 37.0°C Explanation: The normal range for an oral temperature is 37.0°C, a rectal temperature is 37.5°C, an axillary temperature is 36.5°C, and a tympanic temperature is 37.5°C.

A client comes to the cardiovascular intensive care unit (CVICU) directly after a three-vessel coronary artery bypass graft (CABG). The client's orders state "maintain systolic blood pressure >90 but <120." How does this order affect the monitoring of the client's blood pressure?

The nurse will assess blood pressure more frequently to ensure that it does not go beyond the ordered limits Explanation: Vital signs reflect health status, cardiopulmonary function, and overall body function. They are called vital signs because of their importance as indicators of physiological state and response to physical, environmental, and psychological stressors. Changes in vital signs often indicate changes in health. Assessment of vital signs helps nurses to establish a baseline, monitor a client's condition, evaluate responses to treatment, identify problems, and monitor risks for alterations in health. It would not be appropriate to monitor this client's BP every hour or every 4 hours or to delegate the taking of this client's BP to a patient care assistant.

A nurse has assessed the blood pressure of a recently admitted patient and obtained a reading of 128/78 mm Hg. What is this patient's pulse pressure?

50 mm Hg Explanation: The pulse pressure is the difference between the SBP and the DBP and reflects the stroke volume. Normal pulse pressure is approximately 40 mm Hg. The mean arterial pressure is calculated by adding one third of the SBP and two thirds of the DBP. A mean pressure of 60 mm Hg is needed to perfuse the vital organs.

An 86-year-old male patient with a diagnosis of vascular dementia and cardiomyopathy is exhibiting signs and symptoms of pneumonia. The nurse has attempted to assess his temperature using an oral thermometer but the patient is unable to follow directions to close his mouth and secure the thermometer sublingually. As well, he repeatedly withdraws his head when the nurse attempts to use a tympanic thermometer. How should the nurse proceed with assessment?

Assess the patient's temperature by axilla Explanation: The axillary site is an accurate and acceptable alternative when other sites are impractical or contraindicated. Rectal temperatures are contraindicated in cardiac patients; mercury thermometers are not commonly used. It is unacceptable for the nurse to rely solely on subjective assessments to determine whether the patient is febrile.

When assessing a client's pulse, the nurse should be alert to which of the following characteristics?

Rate, rhythm, amplitude and contour, and elasticity. Explanation: Several characteristics should be assessed when measuring the radial pulse: rate, rhythm, amplitude and contour, and elasticity.

Since the nurse is unable to obtain an oversized cuff to assess an adult patient with a large arm, the nurse uses an average-sized cuff. What blood pressure reading will the nurse most likely obtain for this patient?

Reading will be high Explanation: If the blood pressure cuff used is too small and the patient's arm is large, the blood pressure reading will be high. If the blood pressure cuff is too large and the patient's arm is small, the reading will be low. The reading obtained with an inappropriately sized cuff will not be correct. The reading can be obtained; however, the reading will be incorrect.

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?

Rigid Explanation: The older clients artery may feel more rigid, hard, and bent. More rigid, arteriosclerotic arteries account for higher systolic blood pressure in older adults. Normal arteries should feel resilient, straight, and springy.

As adults age, the walls of their arterioles become less elastic, increasing resistance and decreasing compliance. How does this affect the blood pressure?

The blood pressure increases. Explanation: The elasticity and resistance of the walls of the arterioles help to maintain normal blood pressure. With aging, the walls of arterioles become less elastic, which interferes with their ability to stretch and dilate, contributing to a rising pressure within the vascular system that is reflected in an increased blood pressure.

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

Watch chest movement before removing the stethoscope after counting the apical beat Explanation: Because breathing is under voluntary in addition to autonomic control, clients may intentionally or inadvertently alter their breathing rate if they are aware that it is being assessed. To obtain an accurate assessment, observe respirations without alerting the client by watching chest movement before removing the stethoscope after you have completed counting the apical beat. Asking the client to breathe normally may still make the client self-conscious and prevent an accurate measurement. Observing the clients chest movement before calling the client back to the examination room would not be practical due to the distance. Performing the assessment multiple times is unnecessary and time consuming

The nurse is assessing an elderly postsurgical client in the home. To begin the physical examination, the nurse should first assess the client's

vital signs. Explanation: It is a good idea to begin the "hands-on" physical examination by taking vital signs. This is a common, noninvasive physical assessment procedure that most clients are accustomed to.