Ch 5 Assessment

Which of the following would be most appropriate for the nurse to do to determine stroke volume?

Calculate the difference between the diastolic and systolic pressures.

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

Chart the finding and continue with the assessment

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

Client sitting with arm slightly flexed and even with the heart

Which of the following would the nurse need to keep in mind when assessing the blood pressure of a client who is receiving anticoagulant therapy?

The blood viscosity would be thinner, causing the blood pressure to decrease.

The nurse obtains a client's blood pressure when standing and compares it to the measurement obtained while the client was sitting. The client's blood pressure when sitting was 122/72 mmHg. Which finding would suggest to the nurse that the client is experiencing orthostatic hypotension?

98/52 mmHg

The nurse is going to take a blood pressure on a patient who has had a previous left mastectomy with lymph node dissection. What would be an appropriate action by the nurse?

take the blood pressure in the right arm

The nurse is completing the assessment of a client who takes a beta-adrenergic blocker and a diuretic. Which assessment would be most important for the nurse to complete to ensure safety with a client receiving antihypertensive agents?

Evaluating for orthostatic hypotension

The nurse notes that a patient is grimacing. What can the nurse ask the patient to determine the cause of this facial expression?

"Can you tell me where you are experiencing pain?"

The nurse has completed the initial assessment of a client and is now performing data analysis. The nurse obtained a blood pressure reading of 114/70 mm Hg. What is this client's pulse pressure?

44 mm Hg

A client's blood pressure while lying supine is recorded as 124/76 mmHg. The nurse records the client's pulse pressure as which of the following?

48 mmHg

Due to a change in the client's status, a nurse is now assessing a client's temperature by the axillary route. Previously, the client had an oral temperature of 98.4oF. Which finding would the nurse interpret as within the range of the client's previous temperature?

97.4oF

A nurse notes that a client looks much older than his chronologic age. Which of the following conditions would most likely contribute to this appearance?

Alcoholism

Before assessing vital signs, the nurse knows that it is important to assess what?

Any medications the client is currently taking

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

Ashen gray

The nurse palpates a client's pulse and notes that the rate is 61 beats per minute, with an amplitude that is weak and thready. How should the nurse respond to this assessment finding?

Assess the client's pulse at the carotid site.

The nurse is auscultating a client's blood pressure and identifies the portion of the blood pressure cycle reflecting the break in sounds occurring between the first and second sounds. This is known as which of the following?

Auscultatory gap

Ideally, when taking a blood pressure, the patient should be instructed to what?

Avoid smoking for 30 minutes prior to the assessment

The nurse is beginning examination of the client. All the following areas are important to observe as part of the general survey except:

Blood pressure

A 55-year-old bookkeeper comes to the office for a routine visit. The nurse notes that on a previous visit for treatment of contact dermatitis, the client's blood pressure was elevated. She does not have prior elevated readings, and her family history is negative for hypertension. The nurse measures her blood pressure in the office today. Which of the following factors can result in a false high reading?

Blood pressure cuff is tightly fitted.

The nurse is admitting a client to surgical daycare and is assessing the client's vital signs. When obtaining the client's oral temperature, where should the nurse insert the thermometer?

Deep in the posterior sublingual pocket

The nurse is having trouble obtaining the pulse and BP in a patient who is in shock. What device would assist the nurse in obtaining the needed vital signs?

Doppler ultrasound

A nurse is taking a patient's temperature and wants the most accurate measurement, based on core body temperature. What site should be used?

Rectal

The nurse is preparing to assess a client's vital signs. Which vital sign should the nurse assess first?

Temperature

The nurse is assessing a new patient's blood pressure using a manual sphygmomanometer. Which of the following sounds constitutes the patient's systolic blood pressure?

The first appearance of faint but distinctive tapping sounds

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

Which of the following factors affect blood pressure? Select all that apply.

• Ethnicity • Smoking • Weight • Stress

The nurse explains to the client that smoking has what effect on the body? Select all that apply.

• Hypertension • Vasoconstriction • Peripheral vascular disease

The nurse understands that vital signs should be taken with what frequency? Select all that apply.

• Upon admission to unit • With a change in condition • After surgery

A nurse at an ambulatory clinic is preparing to begin the collection of objective assessment data from a female client. After meeting the client and bringing her into the examination room, what instruction should the nurse provide?

"Please have a seat on the edge of the exam table."

The nurse has completed the initial assessment of a client and is now performing data analysis. The nurse obtained a blood pressure reading of 114/70 mm Hg. What is this client's pulse pressure?

"Please have a seat on the edge of the exam table."

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

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

Anxiety

A nurse obtains the blood pressure in a client who is lying down. Which of the following would the nurse expect?

It will be slightly lower than standing readings.

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

Assessment of the pulse amplitude is accomplished by which of the following?

Palpating the flow of blood 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?

Palpitation

A nurse in the surgical daycare department has called a client in from the waiting room and is meeting the client for the first time. The nurse immediately observes that the client has a noticeably "stooped" posture. How should the nurse best follow up this abnormal assessment finding?

Perform a focused assessment of the client's musculoskeletal system

When assessing a client's respirations, what is most important to include in the documentation?

Presence of dyspnea

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

Rate, rhythm, amplitude and contour, and elasticity.

An approximate reading of core body temperature can be taken at various anatomic sites. Which of the following would not be a correct place to take a core body temperature?

Rectum

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

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

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

A nursing instructor is presenting information to nursing students. The instructor addresses the taking of vital signs on clients from other cultures. What would the nurse address about clients from East African cultures?

Use of henna for body decorations

A client's blood pressure is affected by

cardiac output, distensibility of the arteries, blood volume, blood velocity and viscosity.

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?

"Have you been sitting for a long time?"

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

18

A nurse is assessing the blood pressure of a client who has come to the health care facility for the first time. Which of the following is the best site for obtaining the client's blood pressure reading?

Arm

Assessing a client's cognition is part of the general assessment. What is the strongest indicator of a cognitive disorder in a client?

Inappropriate affect

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

Increased pulse rate

A nurse obtains a blood pressure on an elderly client of 160/70 mm Hg. The nurse knows that the term for this condition is what?

Isolated systolic hypertension

The nurse is completing an initial assessment of a client who is new to the ambulatory clinic. Before assessing the client's blood pressure, a nurse asks him what his usual blood pressure is. The nurse bases this action primarily on what rationale?

It indicates the client's involvement in his health care.

A nurse documents a client's radial pulse as 2+, indicated which of the following?

It occludes with moderate pressure.

The nurse is providing care for an 83-year-old woman with a history of hypotension who has been admitted to hospital following a fall. The nurse recognizes the need to assess for orthostatic hypotension. How should the nurse perform this assessment?

Measure the client's heart rate and blood pressure while supine then within 3 minutes of standing.

Two nurses collaborate in assessing an apical-radial pulse on a patient. The pulse deficit is 16 beats/min. What does this indicate?

Not all of the heartbeats are reaching the periphery.

Various sounds are heard when assessing a blood pressure. What does the first sound heard through the stethoscope represent?

Systolic pressure

When documenting assessment data for a patient experiencing a loss of muscle power, it is acceptable to state, "Patient is experiencing muscle fatigue."

false

Osteoporotic thinning and collapse of the vertebrae secondary to bone loss in an elderly client may result in

kyphosis

What site for taking body temperature with a glass thermometer is contraindicated in patients who are unconscious?

oral

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

oral: 37.0°C

The current blood pressure measurement on a 24-hour uncomplicated postoperative patient 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

The nurse assesses the client's vital signs as follows: respirations 20 breaths/minute, tympanic temperature 100.9°F, pulse 88 beats/minute, and blood pressure 104/64 mm Hg. The nurse should

record the vital signs.

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.

• The client is stressed. • The client just finished exercising. • The client is ovulating.

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.

• The client just finished exercising. • The client is ovulating. • The client is stressed.