Chapter 12 Vital Signs *911*

20. A nurse assesses a patient's dorsalis pedis pulse. The pulse is not palpable when light pressure is applied. How should the nurse document this finding? a. Weak pulse b. Normal pulse c. Thready pulse d. Bounding pulse

ANS: A A thready pulse is difficult to feel and is not palpable when only slight pressure is applied. A weak pulse is somewhat stronger than a thready pulse but not palpable when light pressure is applied. A normal pulse is easily felt but not palpable when moderate pressure is applied. A bounding pulse feels full and springlike even under moderate pressure. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 266, Table 11-3 OBJ: 4 | 15 TOP: Pulses KEY: Nursing Process Step: Assessment

30. The nurse assesses the blood pressure as 192/86, noting that the patient has a pulse pressure of .

ANS: 106 one hundred six The pulse pressure is the difference between the diastolic and systolic readings. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 273 OBJ: 7 TOP: Pulse pressure KEY: Nursing Process Step: Assessment

29. If a patient has an axillary temperature of 96.2° F, the nurse understands that the true temperature is .

ANS: 97.2° F Axillary temperatures are considered to be 1° F below core temperature. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 257-259, 261 Skill 11-1 OBJ: 3 TOP: Axillary temperature KEY: Nursing Process Step: Assessment

28. The nurse assesses for the fifth vital sign, which is .

ANS: pain Pain is considered the fifth vital sign. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 253 OBJ: 1 TOP: Pain as a vital sign KEY: Nursing Process Step: Assessment

18. A nurse assesses a neonate's temperature by using a temporal artery scanner. What intervention should the nurse implement if the neonate's temperature is 99.5° F? a. Record the findings b. Notify the physician c. Check the axillary temperature d. Check the tympanic temperature

ANS: A The neonate's temperature normally ranges from 96° to 99.5° F (35.5° to 37.5° C). Temperature regulation is labile (unstable) during infancy because of immature physiological mechanisms. Axillary measurement is considered the least accurate method and is used less frequently since the advent of the tympanic membrane thermometer. Tympanic thermometer readings are suitable for patients of all ages, except infants. PTS: 1 DIF: Cognitive Level: Application REF: Page 258, Box 11-4 OBJ: 8 TOP: Vital signs KEY: Nursing Process Step: Assessment

5. What is the term for a fever that rises and falls but does not return to normal until the patient is well? a. Constant b. Intermittent c. Remittent d. Elevated

ANS: C A remittent fever does not return to normal until the patient becomes well. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 258 OBJ: 9 TOP: Remittent fever KEY: Nursing Process Step: Assessment

17. A nurse assesses a neonate's temperature by using a temporal artery scanner. What intervention should the nurse implement if the neonate's temperature is 96° F? a. Record the findings b. Notify the physician c. Check the axillary temperature d. Check the tympanic temperature

ANS: A The neonate's temperature normally ranges from 96° to 99.5° F (35.5° to 37.5° C). Temperature regulation is labile (unstable) during infancy because of immature physiological mechanisms. Axillary measurement is considered the least accurate method and is used less frequently since the advent of the tympanic membrane thermometer. Tympanic thermometer readings are suitable for patients of all ages, except infants. PTS: 1 DIF: Cognitive Level: Application REF: Page 258, Box 11-4 OBJ: 8 TOP: Vital signs KEY: Nursing Process Step: Assessment

24. When assessing factors that may influence the patient's pulse rate, what should the nurse take into consideration? (Select all that apply.) a. Age b. Sex c. Emotion d. Temperature e. Religion

ANS: A, B, C, D All the options listed can affect the pulse rate except religion. PTS: 1 DIF: Cognitive Level: Application REF: Page 265 OBJ: 5 TOP: Influences on pulse rate KEY: Nursing Process Step: Assessment

27. The physician orders daily weights on a patient residing in a long-term care setting. What actions should the nurse implement to assess weight accurately? (Select all that apply.) a. Weigh patient at the same time each day b. Schedule weighing immediately after breakfast c. Encourage patient to void before being weighed d. Ensure same amount of clothing is worn by patient e. Calibrate by setting scale at zero after each weight

ANS: A, C, D Accurate assessment of weight should occur at the same time each day, preferably at 6 AM before breakfast. The patient should be encouraged to void before being weighed and the same amount of clothing should be worn each day. The scale should be calibrated to zero before (not after) each weight is taken. PTS: 1 DIF: Cognitive Level: Application REF: Page 281-282, Skill 11-6 OBJ: 10 TOP: Weight measurement KEY: Nursing Process Step: Implementation

21. A nurse assesses a patient's dorsalis pedis pulse. The pulse is easily felt but not palpable when moderate pressure is applied. How should the nurse document this finding? a. Weak pulse b. Normal pulse c. Thready pulse d. Bounding pulse

ANS: B A normal pulse is easily felt but not palpable when moderate pressure is applied. A thready pulse is difficult to feel and is not palpable when only slight pressure is applied. A weak pulse is somewhat stronger than a thready pulse but not palpable when light pressure is applied. A bounding pulse feels full and springlike even under moderate pressure. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 266, Table 11-3 OBJ: 4 | 15 TOP: Pulses KEY: Nursing Process Step: Assessment

11. The patient's pulse is below 60. The nurse is aware that the patient is not receiving digoxin. What does the nurse suspect is causing the bradycardia? a. Low exercise tolerance b. Unrelieved severe pain c. Excessive bed rest d. A prone position

ANS: B Bradycardia can result from unrelieved severe pain. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 265 OBJ: 5 TOP: Bradycardia KEY: Nursing Process Step: Assessment

13. What is the term for the exchange of carbon dioxide and oxygen that takes place at the alveolar level? a. Tachypnea b. Internal respiration c. External respiration d. Bradypnea

ANS: B Internal respiration is the exchange of gas at the alveolar level. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 269 OBJ: 6 TOP: Internal respiration KEY: Nursing Process Step: Implementation

8. What does the nurse use the diaphragm of the stethoscope to best assess? a. Carotid sounds b. Lung sounds c. Vascular sounds d. Low-pitched sounds

ANS: B Lung sounds are auscultated by using the diaphragm of the stethoscope. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 265 OBJ: 6 | 9 TOP: Stethoscope use KEY: Nursing Process Step: Implementation

15. The nurse is alarmed when a patient with a severe head injury of the occipital lobe has a respiratory rate of 10 breaths per minute. Where might this finding indicate that there is an injury? a. Cerebellum b. Medulla oblongata c. Cortex d. Cerebrum

ANS: B Rate of respiration is controlled by the medulla oblongata. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 270 OBJ: 6 TOP: Respiratory rate KEY: Nursing Process Step: Assessment

26. The home health nurse is preparing to educate a patient regarding electronic self-blood pressure measurement. What information should the nurse provide regarding this procedure? (Select all that apply.) a. Expect precise values b. Proper measurement techniques are necessary c. Cuff fits over clothing d. Stethoscope is not required e. Recalibration is not necessary

ANS: B, C, D Self-blood pressure monitoring requires proper measurement techniques, cuff is made to fit over clothing, and stethoscopes are not required. Values may be inaccurate and recalibration is necessary at least once a year. PTS: 1 DIF: Cognitive Level: Application REF: Pages 278-279 OBJ: 14 TOP: Self-Blood Pressure Measurement KEY: Nursing Process Step: Implementation

25. A patient is admitted to a medical surgical unit. What factors will determine how frequently vital signs will be assessed? (Select all that apply.) a. Desire of the patient b. Judgment of need by the nurse c. Discretion of the family d. Orders of the health care provider e. Patient's condition

ANS: B, D, E Whether and how frequently vital signs are measured depends on the nurse's judgment of need, orders of the health care provider, and patient's condition. Desire of the patient and family members cannot override these factors, but can be taken into consideration within reason of these factors. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 254-255, Box 11-2 OBJ: 11 TOP: Frequency of vital signs measurement KEY: Nursing Process Step: Implementation

23. When instructing a primary caregiver about keeping a daily log of blood pressure readings, what instructions should the nurse include? (Select all that apply.) a. Take the reading at different times during the day. b. Apply the cuff approximately 2 inches above the antecubital fossa. c. If unable to get a reading the first time, immediately reinflate the cuff. d. Assess pulse with the bell of the stethoscope. e. Apply the cuff snugly.

ANS: B, E Readings for a blood pressure log should be taken at the same time every day on the same arm. The cuff should be applied 2 inches above the antecubital fossa and snugly secured. The pulse should be assessed with the diaphragm of the stethoscope. If unable to get a reading the first time, the cuff should be deflated completely and reinflated after several minutes. PTS: 1 DIF: Cognitive Level: Application REF: Pages 276-278, Skill 11-5 OBJ: 7 TOP: Blood pressure KEY: Nursing Process Step: Assessment

19. A nurse assesses a patient's dorsalis pedis pulse. The pulse is difficult to feel and not palpable when only slight pressure is applied. How should the nurse document this finding? a. Weak pulse b. Normal pulse c. Thready pulse d. Bounding pulse

ANS: C A thready pulse is difficult to feel and is not palpable when only slight pressure is applied. A weak pulse is somewhat stronger than a thready pulse but not palpable when light pressure is applied. A normal pulse is easily felt but not palpable when moderate pressure is applied. A bounding pulse feels full and springlike even under moderate pressure. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 266, Table 11-3 OBJ: 4 | 15 TOP: Pulses KEY: Nursing Process Step: Assessment

1. What part of the body maintains a balance between heat production and heat loss, regulating body temperature? a. Thymus b. Thyroid c. Hypothalamus d. Adrenal glands

ANS: C Body temperature is regulated by the hypothalamus. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 257 OBJ: 9 | 13 TOP: Vital signs KEY: Nursing Process Step: N/A

4. The emergency department nurse quickly assesses the temperature of an unconscious patient who has been outside all night in below-freezing temperatures. What temperature is the nurse aware of that can lead to death? a. 95.2° F b. 93.0° F c. 93.2° F d. 90.8° F

ANS: C Death can occur if the temperature falls below 93.2° F. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 258 OBJ: 9 TOP: Vital signs KEY: Nursing Process Step: Assessment

3. The nurse uses cooling techniques to keep the body temperature below 105° F. What can result from an elevated temperature? a. Excessive thirst b. Excessive perspiration c. Damage to body cells d. Increased heart rate

ANS: C If the temperature exceeds 105° F, normal body cells may be damaged. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 258 OBJ: 8 TOP: Vital signs KEY: Nursing Process Step: Implementation

12. What site should be selected if a peripheral pulse needs to be assessed quickly? a. Radial pulse b. Brachial pulse c. Carotid pulse d. Pedal pulse

ANS: C The carotid site is the best for finding a pulse quickly. PTS: 1 DIF: Cognitive Level: Application REF: Page 266 OBJ: 5 TOP: Carotid KEY: Nursing Process Step: Assessment

14. A patient is suspected of having a cardiac arrhythmia. The nurse is concerned with the findings of an apical rate of 88 and a radial rate of 80. What is the term for the difference between these two rates? a. Pulse pressure b. Unequal pulses c. Pulse deficit d. Tachycardia

ANS: C The difference between radial and apical pulses is called a pulse deficit. PTS: 1 DIF: Cognitive Level: Knowledge REF: Pages 268-269 Box 11-10 OBJ: 5 TOP: Pulse deficit KEY: Nursing Process Step: Assessment

16. The nurse assesses respirations of a patient demonstrating pursed-lip breathing, flared nostrils, and retractions. How will the nurse describe these respirations? a. Tachypnea b. Stertorous c. Dyspnea d. Cheyne-Stokes

ANS: C The patient who is using ancillary muscles to breathe is exhibiting dyspnea. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 271 OBJ: 6 TOP: Dyspnea KEY: Nursing Process Step: Assessment

7. How should the nurse position the earpieces on a stethoscope to ensure optimum reception? a. Backward b. Parallel to the ears c. Toward the face d. Downward

ANS: C To ensure the best reception of sound, place earpieces pointing toward the face. PTS: 1 DIF: Cognitive Level: Application REF: Page 264 OBJ: 9 | 12 TOP: Vital signs KEY: Nursing Process Step: Implementation

6. How should the nurse position the ear pinna when using the tympanic thermometer on a child? a. Upward and back b. Parallel c. Downward and back d. Upward and forward

ANS: C Using the tympanic thermometer for a child, the nurse will tug the ear pinna down and back. PTS: 1 DIF: Cognitive Level: Application REF: Page 262, Skill 11-1 OBJ: 3 | 9 TOP: Tympanic thermometer for a child KEY: Nursing Process Step: Implementation

22. A nurse assesses a patient's dorsalis pedis pulse. The pulse feels full and springlike even under moderate pressure. How should the nurse document this finding? a. Weak pulse b. Normal pulse c. Thready pulse d. Bounding pulse

ANS: D A bounding pulse feels full and springlike even under moderate pressure. A thready pulse is difficult to feel and is not palpable when only slight pressure is applied. A weak pulse is somewhat stronger than a thready pulse but not palpable when light pressure is applied. A normal pulse is easily felt but not palpable when moderate pressure is applied. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 266, Table 11-3 OBJ: 4 | 15 TOP: Pulses KEY: Nursing Process Step: Assessment

9. What is the pulse—the expansion and contraction of an artery— produced by? a. Contraction of the right atrium b. Contraction of the right ventricle c. Contraction of the left atrium d. Contraction of the left ventricle

ANS: D Expansion and contraction of an artery is caused by the ejection of blood from the left ventricle. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 265 OBJ: 4 TOP: Vital signs KEY: Nursing Process Step: Assessment

10. When assessing vital signs on a 40-year-old male, the nurse identifies a pulse rate of 120. What is this pulse interpreted as by the nurse? a. Normal b. Bradycardic c. Arrhythmic d. Tachycardic

ANS: D If the pulse is faster than 100 bpm on an adult patient, it is considered to be tachycardic. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 265 OBJ: 5 TOP: Tachycardia KEY: Nursing Process Step: Assessment

2. What type of body temperature remains relatively constant? a. Surface b. Rectal c. Oral d. Core

ANS: D The core body temperature remains relatively constant. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 257 OBJ: 2 TOP: Vital signs KEY: Nursing Process Step: Assessment

The nurse is performing client education with a 58-year-old man who is being treated for hypertension. What lifestyle modification should the nurse recommend in order to help the client control his blood pressure? A) Reducing his sodium intake B) Ensuring adequate amounts of sleep C) Increasing his intake of soluble fiber D) Performing regular range-of-motion exercises

Ans: A Feedback: Reducing intake of sodium has been shown to significantly reduce blood pressure. Exercise is also important, but range-of-motion (i.e., flexibility) exercises are less effective than aerobic and weight-bearing exercise. Sleep and fiber intake are important aspects of health, but do not have major effects on blood pressure.

A nurse is caring for a client with fever. The nurse is assessing the client's core body temperature. Which of these sites most clearly reflects the client's body temperature? A) Ear B) Rectum C) Axilla D) Mouth

Ans: A Feedback: The ear, or the tympanic membrane, is the peripheral site that most closely reflects core body temperature. The most practical and convenient temperature assessment sites are the ear, mouth, rectum, and axilla. However, the tympanic membrane is most accurately indicative of core temperature.

A nurse is assessing the apical heart rate of a healthy person. In order to hear the heart beats loud and clear, where should the nurse place the stethoscope? A) Slightly below the left nipple B) Over the sternum at the midpoint between the nipples C) Four inches below the left clavicle D) On the center of the rib cage

Ans: A Feedback: The heart beats are best heard or felt in a healthy client slightly below the left nipple in line with the middle of the clavicle. The nurse does not place the stethoscope on the center of the rib cage, between the nipples, or 4 in. below the left clavicle to accurately assess the apical heart rate of a healthy person.

The nurse notes that a client's temperature has increased from 102∞F (38.9∞C) to 104∞F (40∞C). Which of the following is the most appropriate action for the nurse to take in this situation? A) Consult the physician and give antipyretics to the client. B) Provide physical cooling measures to the client. C) Suggest that the client rest and take plenty of fluids. D) Cover the client's head with a cap or a towel.

Ans: A Feedback: The nurse should consult the physician and give the client antipyretics. Antipyreticsódrugs that reduce feverósuch as Tylenol would be helpful in this case when the client's body temperature is between 102∞F and 104∞F (38.9 to 40∞C). Physical cooling measures are used when the temperature exceeds this. When the temperature is below 102∞F (38.9∞C) and the client does not have any chronic medical condition, the nurse will ask the client to take plenty of fluids and rest, and will monitor the fever. The nurse will cover the client's head with a cap or a towel when the client has subnormal temperature, not when the client's temperature is above normal, since this measure helps to reduce heat loss.

A nurse has been asked to record a client's body temperature every hour using a digital thermometer. After recording the temperature, the nurse has discarded the disposable sheath but had to clean the thermometer because it contacted the client's lips. How should the nurse clean the thermometer? A) Soak in isopropyl alcohol. B) Wipe with isopropyl alcohol. C) Soak in water mixed with alcohol. D) Wash with soap and water followed by alcohol.

Ans: B Feedback: A digital thermometer is cleaned by wiping the thermometer with isopropyl alcohol. Glass thermometers, not digital thermometers, are cleaned by soaking in isopropyl alcohol. Digital thermometers are also not cleaned by soaking in water mixed with alcohol.

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? A) Strong pulse B) Thready pulse C) Rapid pulse D) Bounding pulse

Ans: B Feedback: 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 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? A) Ability to read gauge from any direction. B) No stethoscope is required. C) Inexpensive depending on quality. D) Need for readjustment is eliminated.

Ans: B Feedback: An electronic manometer eliminates the need for a stethoscope. However, an electronic manometer requires a calibration check and readjustment every 6 months, unlike a mercury manometer which does not require readjustment. An electronic manometer is expensive depending on quality when compared to an aneroid manometer. A nurse can read the gauge of an aneroid manometer, not an electronic manometer, from any direction.

A nurse is caring for a client with low body temperature. Which of these thermometers should be the nurse's first choice to measure the client's body temperature? A) Glass B) Tympanic C) Electronic D) Digital

Ans: B Feedback: Cold body temperatures are measured with a tympanic thermometer. Clinical thermometers such as glass, electronic, or digital cannot be used as they have no capacity to measure temperatures in hypothermic ranges since the blood flow in the mouth, rectum, or axilla generally is reduced.

A nurse has assessed a client's blood pressure near the beginning of a shift and obtained a systolic blood pressure of 138 mm Hg and a diastolic blood pressure of 71 mm Hg. The systolic blood pressure is characterized by which of the following? A) It represents the client's blood pressure between heart beats. B) It represents peak pressure in the client's arteries. C) It peaks when the client's heart is filling with blood. D) It corresponds directly to the client's heart rate.

Ans: B Feedback: Systolic blood pressure is the pressure within the arterial system when the heart contracts. Diastolic blood pressure is the pressure when the heart relaxes and fills with blood. Both are reflections of pressure in the arterial vessels, not the veins. SBP does not correspond directly with heart rate, though heart rate is one factor among many that influence blood pressure.

When measuring a client's pulse rate, the nurse records 125 bpm. How will the nurse document the information in the medical records? A) Bradycardia B) Tachycardia C) Slow pulse rate D) Heart palpitations

Ans: B Feedback: Tachycardia (100 to 150 bpm) is a fast heart rate. In tachycardia, the heart and pulse rates can exceed 150 bpm as well. Bradycardia, or a slow pulse rate, occurs in adults if the heart rate falls below 60 bpm. Heart palpitations represent the physical sensation of irregularities in the beating of the heart.

A nurse is assessing a client's vital signs at a health care facility. The nurse observes that the client is sweating profusely. Which of the following causes a client to sweat? A) Medulla B) Hypothalamus C) Cerebellum D) Pituitary gland

Ans: B Feedback: The anterior hypothalamus promotes heat loss through vasodilation and sweating. In humans, the hypothalamus acts as the center for temperature regulation. The posterior hypothalamus promotes heat conservation and heat production. The medulla, which contains the respiratory center in the brain, controls ventilation whereas the pituitary gland secretes hormones for a variety of regulatory functions. The cerebellum regulates balance.

A nurse is caring for a client with subnormal temperature. Which of the following actions should the nurse perform to provide heat to the client's internal organs? A) Raise the room temperature B) Provide warm fluids C) Apply layers of dry clothing D) Warm blankets in a blanket warmer

Ans: B Feedback: The nurse should provide the client with warm fluids because fluids conduct heat to internal organs. Raising the room temperature warms the body surface, not the internal organs, whereas applying layers of dry clothing helps trap body heat next to the skin. Warming blankets and clothing in a blanket warmer or microwave helps to raise the temperature of woven fabrics and thus body surfaces, but not necessarily the temperature of organs.

A nurse is caring for a client who has a lack of appetite. Which of the following is most likely to influence a client's core body temperature? A) Minerals B) Proteins C) Fiber D) Vitamins

Ans: B Feedback: The nurse should recommend an increase in protein in the client's diet as it has the greatest thermic effect. Food intake, or lack of it, affects thermogenesis or heat production. When a person consumes food, the body requires energy to digest, absorb, transport, metabolize, and store nutrients. Thus, both the amount and the type of food eaten affect body temperature. Dietary restrictions can contribute to decreased body heat as a result of reduced processing of nutrients. Increased intake of fiber would lead to decreased heat production. Vitamins and minerals would not help in increasing the client's appetite, nor would they affect temperature.

A nurse needs to measure the blood pressure of a client who has just undergone a bilateral mastectomy. How should the nurse measure the blood pressure? A) Over the lower arm B) Brachial artery C) Over the client's thigh D) Radial artery

Ans: C Feedback: The nurse should measure the blood pressure over the client's thigh or the popliteal artery behind the knee. It is inadvisable post-mastectomy to assess blood pressure at the normal site, which is over the brachial artery at the inner aspect of the elbow. In normal cases, the blood pressure may also be assessed at the lower arm and radial artery.

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? A) The amount of oxygen available to tissues throughout the body B) The volume of the venous system relative to the volume of the arterial system C) The size of the client's heart muscle D) The resistance that the client's heart must overcome when pumping blood

Ans: D Feedback: 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.

A nurse has responded to a client's call light and found the client gasping and saying, ìI can't get my breath.î The nurse applied supplementary oxygen and repositioned the client which led to the relief of the client's symptoms. When documenting this event, the nurse should note that the client was experiencing: A) Bradypnea B) Orthopnea C) CheyneñStokes breathing D) Dyspnea

Ans: D Feedback: Dyspnea is difficult or labored breathing. Bradypnea is an abnormally slow breathing rate and orthopnea is breathing facilitated by sitting up or standing. CheyneñStokes respiration refers to an ominous breathing pattern in which the depth of respirations gradually increases, followed by a gradual decrease, and then a period when breathing stops briefly before resuming again.

A nurse has applied a blood pressure cuff to a client's upper arm, positioned the stethoscope over the client's brachial artery, inflated the cuff and is now slowly releasing air from the cuff. The nurse should recognize the client's peak blood pressure when what sound is audible? A) A whooshing sound that quickly intensifies B) A clicking sound that appears suddenly C) The ìlub dubî of the client's heart rate D) A faint, clear tapping sound

Ans: D Feedback: Korotkoff sounds have five unique phases. Phase I begins with the first faint but clear tapping sound that follows a period of silence as pressure is released from the cuff. When the first sound occurs, it corresponds to the peak pressure in the arterial system during heart contraction, or the systolic pressure measurement. This sound does not have the two-stage sound of a heartbeat.

A nurse is caring for a newborn. The nurse knows that the body temperature of infants is prone to fluctuations. Which of these is the most probable cause for fluctuations in the infant's body temperature? A) Large amount of subcutaneous white adipocytes or fat cells B) Increased ability to shiver and perspire C) Ability to independently forestall or reverse heat loss or gain D) Great surface area relative to mass and very high metabolic rate

Ans: D Feedback: Newborns and young infants tend to experience temperature fluctuations because they have a three times greater surface area relative to their mass from which heat is lost and a metabolic rate twice that of adults. Infants and older adults have difficulty maintaining normal body temperature because they have limited, not large, amounts of subcutaneous white adipocytes, fat cells that provide heat insulation and cushioning of internal structures. The ability of both young and old to shiver and perspire also may be inadequate, putting them at risk for abnormally low or high body temperatures. Infants and older adults are less able to independently forestall or reverse heat loss or gain than are other clients. However, the main cause for fluctuations in infants' body temperature is because they have a three times greater surface area relative to their mass from which heat is lost and a metabolic rate twice that of adults.

A nurse needs to count a client's apical heart rate. Which of the following assessment sites is most suitable for counting the apical heart rate? A) Wrist B) Neck C) Inner elbow D) Chest

Ans: D Feedback: The apical heart rate is counted by listening at the chest with the stethoscope or by feeling the pulsations in the chest for one minute at an area called the point of maximum impulse (PMI), which is located at the surface of the skin over the apex of the heart. The wrist, neck, and brachial sites are not apical heart rate sites but peripheral pulse sites.

A nurse is assessing a client's body temperature. For which of the following clients could the nurse obtain an accurate body temperature at the oral site? A) A client who is very young B) A client after an oral surgery C) A client who is confused and talkative D) A client with a nasogastric tube in situ

Ans: D Feedback: The nurse can obtain an accurate body temperature at the oral site for a client with a nasogastric tube in situ. Oral temperature measurement is contraindicated in a client after an oral surgery. The nurse cannot obtain an accurate body temperature at the oral site for clients who are very young and clients who continue to talk during temperature assessment.