NU273 Chapter 8: Assessing General Status and Vital Signs

The nurse is caring for a client who is having nothing by mouth (NPO) on the first postoperative day. The client's blood pressure was 120/80 mm Hg approximately 4 hours ago, but it is now 140/88 mm Hg. The nurse should ask the client which of the following questions? "Do you have enough blankets to stay warm?" "What is your typical blood pressure reading?" "Are you taking any medications for hypertension?" "Are you having pain from your surgery?"

"Are you having pain from your surgery?" Explanation: A client's blood pressure will normally vary throughout the day due to external influences. This includes pain.

A nurse notes that the pulse rate of a client is less than 60 beats per minute. Which question is appropriate for the nurse to ask the client in regards to this finding? "What vitamin supplements are you currently taking?" "How is your stress level today?" "Are you feeling feverish today?" "Have you been sitting for a long time?"

"Have you been sitting for a long time?" Explanation: Sitting or standing for too long may cause the blood to pool and decrease the pulse rate. Fever and stress cause the pulse rate to increase, not decrease. Vitamin supplements do not affect the pulse rate.

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? 160/85 mm Hg 120/55 mm Hg 140/55 mm Hg 130/65 mm Hg

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.

A nurse measures a client's blood pressure at 174/102 mm Hg. The nurse recognizes this as what classification of blood pressure measurement? Normal Stage 1 hypertension Prehypertension Stage 2 hypertension

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.

A normal pulse pressure range for an adult client is typically 40 to 60 mm Hg. 30 to 50 mm Hg. 60 to 80 mm Hg. 20 to 40 mm Hg.

30 to 50 mm Hg. Explanation: A normal pulse pressure is 30 to 50 mmHg.

A nurse is preparing to assess a client's vital signs. In which order should the nurse assess them? Respirations, blood pressure, pulse, and temperature Temperature, pulse, respirations, and blood pressure Pulse, temperature, respirations, and blood pressure Blood pressure, temperature, pulse, and respirations

45 to 60 Explanation: The normal pulse rate of a well-conditioned athletic client is often less than 60 beats per minute because of the conditioning of the cardiovascular system. A pulse rate ranging between 60 and 100 beats/min is normal for adults. A pulse rate of more than 100 beats/min would indicate tachycardia.

A nurse has assessed the blood pressure of a recently admitted client and obtained a reading of 128/78 mm Hg. What is this client's pulse pressure? 50 mm Hg 128 mm Hg 78 mm Hg 103 mm Hg

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.

The nurse is seeing an older client who has not had medical care for many years. Vital signs are T 37.2, HR 78, BP 118/92, RR 14. The client denies pain. The nurse notices that the client has some hypertensive changes in her retinas; a urine test reveals mild proteinuria. The nurse expected the client's BP to be higher. The client is not taking any medications. What do you think is causing this BP reading? Resolution of the process that caused her retinopathy and kidney problems An auscultatory gap The client's emotional state A cuff size error

An auscultatory gap Explanation: The blood pressure is unusual in this case because the systolic pressure is normal while the diastolic pressure is elevated. Especially with the retinal and urinary findings, the nurse should consider that the BP may be much higher and that an auscultatory gap was missed. This can be avoided by checking for obliteration of the radial pulse while the cuff is inflated. Although a large cuff can cause a slightly lower BP on a client with a small arm, this does not account for the elevated DBP. Emotional upset usually causes elevation of the BP. Although a process that caused the retinopathy and kidney problems may have resolved, leaving these findings, it is a dangerous assumption that this is the sole cause of the problems seen in this client.

The nurse should immediately notify the healthcare provider if which assessment finding is obtained on a hospitalized client? Temperature 37.5 Celsius Moderate amount dark blood on dressing Cyanotic left lower extremity Heart rate of 105 beats per minute

Cyanotic left lower extremity Explanation: An acutely cold, cyanotic, or pulseless extremity should be reported to the healthcare provider immediately. A temperature below 39.0 Celsius, bright red bleeding, and a heart rate greater than 120 beats per minute or less than 50 beats per minute are not considered urgent findings.

The nurse is performing vital signs during the routine assessment of an adult client who twisted his ankle during a mini-marathon. The client's pulse is 52 bpm. The nurse retakes the pulse; the finding is the same. The client tells the nurse that he has been training for 6 months for this mini-marathon. What should the nurse do in regard to this reading? Notify the physician immediately Give oxygen at 2 liters per nasal cannula Lower the head of the bed Document the finding

Document the finding Explanation: A well-conditioned athlete may have a heart rate in the range of 50 to 60 bpm. It would not be appropriate to notify the physician immediately, give the client oxygen, or lower the head of the bed.

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. Which nursing diagnosis can be confirmed from this data? Hypertension Acute confusion Dressing self-care deficit Risk for activity intolerance

Dressing self-care deficit Explanation: From the data gathered, the nurse can confirm the diagnosis of dressing self-care deficit related to impaired ability to perform or complete dressing and grooming activities for oneself related to the presence of left-sided weakness. Acute confusion cannot be confirmed because the criteria of disturbances in cognition, psychomotor activity, and level of consciousness are not present. Activity intolerance is a state in which an individual has insufficient physiologic or psychological energy to endure or complete required or desired daily activities. Hypertension is a potential complication and not a nursing diagnosis.

An older adult client with COPD has come to the clinic for a routine follow-up visit. The nurse escorts the client to an examination room and measures vital signs. The nurse would expect the client's vital signs to be what? Higher than normal Lower than normal Within normal limits The nurse would not routinely take this client's vital signs

Higher than normal Explanation: Many variables can lead to increased vital signs, including pain, stress, anxiety, activity, and chronic disease processes. It is imperative that nurses measure vital signs correctly and accurately, understand the data, and communicate the findings appropriately. COPD is often a result of smoking and likely result in an increase in vital signs. The client's vital signs would be assessed at each clinic visit.

The nurse explains to the client that smoking has what effect on the body? Select all that apply. Hypertension Vasodilation Vasoconstriction Peripheral vascular disease Hypotension

Hypertension Vasoconstriction Peripheral vascular disease Explanation: Smoking can cause vasoconstriction, hypertension and peripheral vascular disease, not vasodilation and hypotension.

Before completing the physical examination, the nurse determines that the client is awake, alert, and oriented. This information would be important for which part of the general survey? Level of consciousness Posture, gait, motor activity, and speech Apparent state of health Facial expression

Level of consciousness Explanation: Being awake, alert, and oriented is a part of the level of consciousness category within the general survey. Descriptions of apparent state of health include if the client looks his or her age, appears ill, appears unhappy, or appears fatigued. Eye contact and facial movements are characteristics of the facial expression category within the general survey. Walking, posture, speech pattern, and movement of the limbs are characteristics of the posture, gait, motor activity, and speech category within the general survey.

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 Observe the client's chest movement before calling the client back to the examination room Ask the client to breathe normally Perform the assessment at the beginning, middle, and end of the examination and average the results

Marfan syndrome Explanation: Arm span is greater than height and pubis to sole measurement exceeds pubis to crown measurement in Marfan syndrome. In gigantism, there is increased height and weight with delayed sexual development. Extreme weight loss is seen in anorexia nervosa. Central body weight gain with excessive cervical obesity (Buffalos hump), also referred to as endogenous obesity, is seen in Cushing syndrome.

A client recovering from a stroke complains of pain. The nurse suspects this client is most likely experiencing which type of pain? Nociceptive Idiopathic Somatic Neuropathic

Neuropathic Explanation: Neuropathic pain can occur from central nervous system brain injury caused by a stroke. Nociceptive pain is caused by tissue damage. Somatic pain is another term used for nociceptive pain. Idiopathic pain does not have an identified cause.

The nurse aide reports to the nurse that an older adult client has abnormal vital signs. What is important to remember in this type of situation? At client's age, abnormal vital signs are an indication of something serious Normal readings get lower with advanced age Normal readings vary according to age Normal readings get higher with advanced age

Normal readings vary according to age Explanation: When encountering an abnormal value, the nurse should obtain the vital sign(s) again to assess accuracy. The nurse should also consider whether the client appears to be in distress, noting skin color, respiratory effort, and behavior. Normal readings vary according to age.

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? Infuse IV fluids Administer diuretics Notify the rapid response team Reassess client in one hour

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.

The nurse is seeing an older client who has not had medical care for many years. Vital signs are T 37.2, HR 78, BP 118/92, RR 14. The client denies pain. The nurse notices that the client has some hypertensive changes in her retinas; a urine test reveals mild proteinuria. The nurse expected the client's BP to be higher. The client is not taking any medications. What do you think is causing this BP reading?

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.

Assessment of the pulse amplitude is accomplished by which of the following? Palpating the flow of blood through an artery Auscultating the flow of blood through an artery Auscultating the area of the left ventricle Palpating the area of the left ventricle

Palpating the flow of blood through an artery Explanation: The pulse amplitude describes the quality of the pulse in terms of its fullness and reflects the strength of left ventricular contraction. It is assessed by the feel of the blood flowing through an artery.

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? Apical beats Dyspnea Pulse pressure Palpitation

Palpitation Explanation: An alteration in heartbeat felt by a client is called a palpitation and can be caused by various circumstances including thyroid dysfunction, medication reaction, or alteration in fluid volume. Dyspnea is difficulty breathing. Pulse pressure is the difference between systolic and diastolic blood pressures. Apical beats are simply the beats of the heart palpated directly over the apex of the heart, on the chest.

When assessing a client's respirations, what is most important to include in the documentation? Position of the client Assessment of pedal pulses Presence of dyspnea Numerical pain rating

Presence of dyspnea Explanation: The presence of dyspnea is the most important of the choices listed to include in the documentation. Dyspnea can be an indicator of potential respiratory distress. The presence of pain and position of the client can impact the client's respiratory status, but are not the primary piece of information to include in the documentation. Assessment of pedal pulses is a component of a circulatory assessment.

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 strong and remains despite moderate pressure. Pulse is felt with difficulty and disappears with slight pressure. Pulse is felt easily, and moderate pressure causes it to disappear. Pulse is strong, and light pressure causes it to disappear.

Pulse is felt with difficulty and disappears with slight pressure. Explanation: Thready pulse is felt with difficulty or not easily felt, and slight pressure causes it to disappear. A weak pulse is stronger than a thready pulse, and light pressure causes it to disappear. A normal pulse is felt easily, and moderate pressure causes it to disappear. A bounding pulse is strong and does not disappear with moderate pressure.

A nurse is assessing the blood pressure on an obese woman. What error might occur if the cuff used is too narrow? Reading is erroneously high. It will be difficult to pump up the bladder. Pressure on the cuff would be painful. Reading is erroneously low.

Reading is erroneously high. Explanation: The bladder of the cuff should enclose at least two-thirds of the adult limb. If the cuff is too narrow, the reading could be erroneously high because the pressure is not being transmitted evenly to the artery.

The nurse is taking routine vital signs toward the end of shift. A client's BP reads 204/148. The client's baseline BP has been in the 130's systolic. What should the nurse do first? Retake the blood pressure Give PRN blood pressure medications Document the findings Notify the physician immediately

Retake the blood pressure Explanation: When encountering an abnormal value, obtain the vital sign(s) again to assess accuracy. It would be inappropriate to notify the physician immediately, give PRN blood pressure medications, or document the findings before rechecking the reading.

You are educating your client on taking blood pressure at home. What would be important to include in your client education? Monthly replacement of batteries Routine recalibration of the device Application of a thigh cuff Use of a wrist cuff

Routine recalibration of the device Explanation: Follow the guidelines listed, and advise your clients about how to choose the best cuff for home use. Urge them to have their home devices recalibrated routinely.

A client recovering from abdominal surgery is complaining of pain. The nurse realizes that the client is most likely experiencing which type of pain? Neuropathic Psychogenic Somatic Idiopathic

Somatic Explanation: Somatic pain is a type of nociceptive pain. Somatic pain results from damage to the skin, muscles, and soft tissues, which would occur during abdominal surgery. It tends to be relatively intense and localized to the area of injury. Psychogenic pain relates to factors that influence the client's report of pain such as anxiety and depression. Idiopathic pain does not have an identified cause. Neuropathic pain results from direct injury to the peripheral or central nervous system.

A nurse is assessing the pulse rate of an athletic client during a routine checkup. The nurse should anticipate the pulse rate to be in what range of beats per minute? 85 to 100 105 to 120 45 to 60 65 to 80

Stage 2 hypertension Explanation: The latest guidelines (November 2017) released by the American College of Cardiology and the American Heart Association are: Normal blood pressure: Systolic less than 120 mm Hg and diastolic less than 80 mm Hg. Elevated blood pressure: Systolic between 120 and 129 mm Hg and diastolic less than 80 mm Hg. Stage 1 hypertension: Systolic between 130 and 139 mm Hg or diastolic between 80 and 89 mm Hg. Stage 2 hypertension: Systolic of 140 or greater mm Hg or diastolic of 90 or greater mm Hg.

Various sounds are heard when assessing a blood pressure. What does the first sound heard through the stethoscope represent? Auscultatory gap Systolic pressure Pulse pressure Diastolic pressure

Systolic pressure Explanation: The first sound heard through the stethoscope, which is the onset of phase I of Korotkoff sounds, represents the systolic pressure.

Upon entering an adult client's room to begin a shift assessment, the nurse should call the rapid response team based on which assessment finding? Systolic pressure 180 mm Hg. Respirations 12 breaths/minute. Apical pulse 70 beats/minute. Oxygen saturation 95% on room air.

Systolic pressure 180 mm Hg. Explanation: The nurse may call a rapid response team if the client displays the following: respirations less than 10 breaths/min; oxygen saturation less than 92%; pulse less than 55 beats/min or greater than 120 beats/min; systolic blood pressure less than 100 or greater than 170 mm Hg.

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

Temperature, pulse, respirations, and blood pressure Explanation: When assessing the vital signs of the client, the nurse should begin by measuring the clients temperature, to put the client at ease and to quiet the client for better assessment of the remaining vital signs. Pulse, respirations, and blood pressure can be altered by anxiety and activity.

A nurse is assessing the blood pressure of a team of healthy athletes at the heath care facility. Which of the following observations can be made by the nurse and athletes by measuring the blood pressure? The ability of the arteries to stretch The oxygen levels in the blood The thickness of the circulating blood The volume of air entering the lungs

The ability of the arteries to stretch Explanation: Measuring the blood pressure helps to assess the efficiency of the client's circulatory system. Blood pressure measurements reflect the ability of the arteries to stretch, the volume of circulating blood, and the amount of resistance the heart must overcome when it pumps blood. Measuring the blood pressure does not help in assessing the thickness of blood, oxygen level in the blood, or the volume of air entering the lungs. Reference:

A nurse observes that a young man's arm span appears to be greater than his height. Which condition should the nurse suspect in this client? Marfan syndrome Anorexia Gigantism Cushing's syndrome

The client has just run 4.82 km (3 miles) outside before coming to the interview. Explanation: Several factors may cause normal variations in the core body temperature. Strenuous exercise can raise temperature.

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 160/85 mm Hg 140/55 mm Hg 130/65 mm Hg

To see the client before the client assumes a social face or behavior Explanation: If possible, try to observe the client and environment quickly before interacting with the client. This gives you the opportunity to see the client before the client assumes a social face or behavior and allows you to glimpse any distress, sadness, or pain before the client, knowingly or unknowingly, may mask it. An initial observation of the client from a distance would not be effective for assessing for skin lesions. Trying to overhear the client conversation with a family member would be inappropriate. You may determine whether you recognize the client from a previous visit by a quick observation, but this is not the primary rationale for this action.

Students are touring the hospital before starting their clinical rotations. The instructor points out that the type of thermometer used in this facility is noninvasive, safe, efficient, and quick. What type of thermometer is theinstructor describing?

Tympanic Explanation: Tympanic thermometers use infrared sensors to detect the heat that the tympanic membrane produces. The tympanic membrane thermometer is noninvasive, safe, efficient, and quick. Because the reading is so quick (2 to 3 seconds), it is commonly used in emergency departments and hospitals.

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 the best rationale for this action? To determine whether you recognize the client from a previous visit To see the client before the client assumes a social face or behavior To overhear the client's conversation with a family member To check the client for skin lesions the client may not be aware of

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 begins a client assessment by conducting a general survey that focuses on objective observations. What is the primary purpose for collecting this sort of information first? demonstrates the nurse's therapeutic interest in the client assists the nurse in formulating appropriate subjective questioning permits the nurse to initiate the assessment in a nonthreatening manner allows the nurse to form an effective nurse-client relationship

assists the nurse in formulating appropriate subjective questioning Explanation: The General Survey chapter provides an overview of the nurse's initial client assessment prior to exploring each system in detail. The objective observation of the client begins with the first moments of the encounter and continues throughout the history and physical examination. The nonverbal cues collected during the general survey enable the nurse to select appropriate subjective questions for the individual client to garner more information. While the remaining options are true statements concerning a general survey, none demonstrate the primary purpose for the collection of objective information. Reference:

A client has an oral temperature of 37.2 °C (99 °F). The nurse interviews the client. Which of the following pieces of interview data could be an influence on this high body temperature? The client reports having a toe infection treated with antibiotics 3 months ago. The client has just run 4.82 km (3 miles) outside before coming to the interview. The client has a history of hypothyroidism. The client drinks eight glasses of water a day.

cardiac output, distensibility of the arteries, blood volume, blood velocity and viscosity. Explanation: Blood pressure is the pressure exerted by blood on the walls of the arteries. It is affected by cardiac output, distensibility (elasticity) of the arteries, blood volume, blood velocity, and blood viscosity (thickness).

The nurse is preparing to assess an adult client in the clinic. The nurse observes that the client is wearing lightweight clothing that is worn and soiled, although the temperature is below freezing outside. The nurse anticipates that the client may be abusing drugs. a victim of abuse. anxious. lacking adequate finances.

lacking adequate finances. Explanation: When you meet the client for the first time, observe any significant abnormalities in the client's skin color, dress, hygiene, posture and gait, physical development, body build, apparent age, and gender. If you observe abnormalities, you may need to perform an in-depth assessment of the body area that appears to be affected.

While caring for an 80-year-old client in his home, the nurse determines that the client's oral temperature is 35.8 °C (96.5 °F). The nurse determines that the client is most likely exhibiting an immune disorder resulting in low platelet count. hypothermia that occurs before an infectious process. normal changes that occur with the aging process. a metabolic disorder resulting in circulatory changes.

normal changes that occur with the aging process. Explanation: In the older adult, temperature may range from 95.0°F to 97.5°F. Therefore, the older client may not have an obviously elevated temperature with an infection or be considered hypothermic below 96°F.

The current blood pressure measurement on a 24-hour uncomplicated postoperative client while standing at the bedside is 105/65. The last two readings were 130/75 and 125/70 while resting in bed. The nurse should be alert for signs of: orthostatic hypotension. supine hypotension. hypertensive crisis. postural hypertension.

orthostatic hypotension.

The nurse is having difficulty auscultating Korotkoff sounds. The nurse should (Select all that apply.) be certain there is full skin contact with the bell consider shock keep the cuff inflated for 30 seconds before auscultating request an ECG reposition the stethoscope

reposition the stethoscope consider shock be certain there is full skin contact with the bell