Chapter 8: Assessing General Status and Vital Signs

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

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.

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 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.

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?

1+ Explanation: Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 8: Assessing General Status and Vital Signs, STRUCTURE AND FUNCTION, Vital Signs, p. 118.

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?

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 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.

A nurse is taking a rectal temperature on an unconscious client. What reading would reflect temperature within the normal range?

99°F Explanation: The normal rectal temperature range is around 37°C (99°F). A rectal temperature above 100°F or at 97°F is outside the normal range. Rectal temperatures are about 0.5°C (0.8°F) higher than oral temperatures.

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

Any medications the client is currently taking Explanation: Prior to assessing vital signs, it is important to assess any medications the client is currently taking because medications can affect a client's vital signs. It is not necessary to know the client's height and weight, mental status, or a complete family history before assessing vital signs because these things do not affect a client's vital signs.

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

"Are you currently experiencing any pain?" Explanation: From the client's facial expression of a grimace, the nurse needs to determine whether the client is experiencing pain. The best question that the nurse can ask is whether the client is experiencing pain now. Asking if the client has a question to ask does not address the client's facial grimace. Asking if the client is uncomfortable sitting in a chair assumes that the cause of the facial grimace is discomfort when sitting in a chair. Asking if the client when the pain started assumes that the client's facial grimace is a result of pain.

Which general survey question focuses on the common "fifth vital sign"?

"Are you experiencing any pain right now?" Explanation: The "vital signs" include blood pressure, heart rate, respiratory rate, and temperature. Although pain is a subjective finding, it has been labeled the "fifth vital sign." While the assessment of mood is appropriate, it is not associated with the "fifth vital sign."

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?

"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?

"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.

Which statement by a nurse concerning the various methods used to measure temperature indicates the need for additional education?

"When monitoring the same client, an axillary temperature is usually higher by a degree than an oral temperature." Explanation: The average oral temperature fluctuates considerably. In the early morning hours, it may fall as low as 35.8° C (96.4° F), and in the late afternoon or evening it may rise as high as 37.3° C (99.1° F). Rectal temperatures are higher than oral temperatures by an average of 0.4 to 0.5° C (0.7 to 0.9° F). In contrast, axillary temperatures are lower than oral temperatures by approximately 1°. Tympanic membrane temperatures can be more variable than oral or rectal temperatures.

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.

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.

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 Explanation: A respiratory rate of 18 breaths/min would be normal for this client. In older adults, the normal respiratory rate would range between 15 and 22 breaths/min. Respiratory rates of fewer than 15 breaths/min or more than 22 breaths/min would be an abnormal respiratory rate for this client.

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?

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.

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 Explanation: The major defining characteristics of anxiety are present: loss of sleep, feeling unsafe, inability to concentrate, and poor eye contact. There are no major characteristics for the nursing diagnosis of imbalanced nutrition: less than body requirements, risk for self-directed violence, or impaired verbal communication.

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 Explanation: The first time the blood pressure is measured, it is assessed in each arm. The two blood pressure measurements should not vary more than 5 to 10 mm Hg unless pathology (disease) is present. The blood pressure is not measured in shoulders, wrist, or thighs of clients for the first time. Nurses use the thigh to assess the blood pressure when they cannot obtain readings in either of the client's arms.

When can the general inspection be started?

As soon as the examiner first sees the client Explanation: The first moments of interaction between client and examiner should constitute the beginning of the general inspection. This should not wait until after height and weight have been measured or until the client is completely exposed. It is not possible to begin a general inspection prior to seeing (or smelling or hearing) the client.

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.

An 86-year-old male client 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 client 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 client'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 clients; mercury thermometers are not commonly used. It is unacceptable for the nurse to rely solely on subjective assessments to determine whether the client is febrile.

After assessing a client's radial pulse, the nurse determines that an apical pulse needs to be assessed. What will the nurse do when assessing the apical rate? (Select all that apply.)

Assess the rate for 1 minute. Place the stethoscope at the apex of the heart. Explanation: In the event of an irregular radial pulse, the apical pulse should be assessed. The apical pulse should be assessed for 1 minute with the stethoscope placed at the apex of the heart. The apical heart rate should be assessed for 1 full minute and not for 30 seconds and multiplied by 2. The nurse will have difficulty assessing both the radial and the apical pulses at the same time. Having the client sit quietly for 5 minutes before assessing is appropriate for assessing blood pressure and not the apical pulse.

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

Avoid smoking for 30 minutes prior to the assessment Explanation: Ideally, instruct the client to avoid smoking or drinking caffeinated beverages for 30 minutes before the blood pressure is measured.

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 Explanation: Blood pressure is a vital sign, not part of the general survey. Apparent age, signs of distress, and appearance are all parameters of the general survey.

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. Explanation: A blood pressure cuff that is too tightly fitted can result in a false high reading. Resting prior to assessment, measuring on a bare arm, and supporting the client's arm at mid-chest level all foster accurate BP measurement.

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

Bradycardia Explanation: A heart rate or pulse of 60 beats per minute is termed bradycardia. Normal heart rate for the adult is between 60 and 100 beats per minute. Tachycardia describes a heart rate over 100 beats per minute. Hypocardia refers to a heart that is not beating with enough force.

During the physical assessment of a client, a nurse observes that the client tends to lean forward, using the arms to support the upper body. The nurse recognizes this as a sign of what disease process?

Chronic obstructive pulmonary disease Explanation: Chronic obstructive pulmonary disease (COPD) can cause clients to lean forward and brace themselves with their arms. This is known as the "tripod position" and can aid in breathing. Stiff, rigid movements are common in clients with arthritis or Parkinson disease. Osteoporotic thinning is common in older adult clients.

On which health problem should the nurse focus when assessing this client?

Cushing's syndrome Explanation: Central body weight gain with excessive cervical obesity (Buffalo's hump), also referred to as endogenous obesity, is seen in Cushing's syndrome. Excessive body fat that is evenly distributed is referred to as exogenous obesity. Overgrowth of bones in the face, head, hands, and feet with normal height is seen in acromegaly. Arm span that is greater than height, and pubis to sole measurement exceeds pubis to crown measurement is seen in Marfan syndrome.

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

Date and location of the clients last blood pressure check Onset and character of the clients chest pain A list of all of the client's current medications Explanation: Subjective findings, which are those the client must report to the nurse, include date and location of the clients last blood pressure check, the onset and character of the clients chest pain, and a list of all of the clients current medications. Objective findings, which are obtained by the nurses direct observation or assessment, include respiratory rate, core body temperature, and blood pressure.

Body temperature is not impacted by which of the following factors?

Diet Explanation: Body temperature varies with diurnal cycle, physical activity, age, gender, and state of health. It also normally fluctuates with activity and time of day. Diet does not affect a client's body temperature, though if a client has consumed hot or cold food or beverages before having an oral temperature taken, the reading may be impacted. To ensure accuracy, the nurse should wait 15-30 minutes to take temperature after the client has had anything hot or cold to eat or drink, has smoked, or has chewed gum.

The paramedics are called to a gym to see an individual who has been exercising and developed pain in the upper right quadrant of the abdomen. The initial vital sign reading indicates a pulse of 175 beats per minute. This pulse would be considered what? (Mark all that apply.)

Elevated due to pain Elevated due to anxiety Elevated due to activity Explanation: Variables that can affect vital signs include pain, stress, anxiety, and activity. The individual's weight is not mentioned in the scenario, nor is that the individual is dehydrated.

The nurse is reviewing the chart of a newly admitted client and identifies the client has Marfan syndrome. What assessment finding would the nurse expect to find?

Elongated fingers Explanation: Marfan syndrome is characterized by elongated limbs and fingers. Elongated bones of the face and hands are associated with acromegaly. Client's with Cushing's syndrome exhibit weight gain in the chest, stomach and neck. Decreased height and skeletal malformations are associated with dwarfism.

A nurse is teaching a class on hypertension in a community setting. What risk factor would the nurse be sure to address to the class?

Family history Explanation: Clients should be educated about the risks of hypertension. Risk factors include obesity, cigarette smoking, heavy alcohol consumption, prolonged stress, high cholesterol and triglyceride levels, family history, and renal disease. Weight loss, low triglyceride level, and smoking cessation are not risk factors for hypertension.

The client is exercising. The nurse understands that exercise has what effect on the body? Select all that apply.

Increased heart rate Increased blood pressure Increased cardiac output Explanation: During exercise, the blood pressure, heart rate and cardiac output increase. Peripheral vascular resistance is related to circulatory disorders.

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 Explanation: The elderly are prone to isolated systolic hypertension (systolic greater than 140 but diastolic under 90) due to arteriosclerosis that makes blood vessels stiff and less compliant. Orthostatic hypotension is a blood pressure that drops when a client changes positions. Stage 1 hypertension is a blood pressure reading of 140 to 159/90 to 99 mm Hg. Hypertension is not normal for any client.

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 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.

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 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.

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. Explanation: Orthostatic blood pressure is measured by recording blood pressure and heart rate with the client in two positions supine after the client is resting up to 10 minutes, then within 3 minutes after the client stands up. Usually, as the client rises from the horizontal to the standing position, systolic pressure drops slightly or remains unchanged, while diastolic pressure rises slightly.

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?

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 client fell while attempting to transfer from her bed to a commode. Which of the following health problems should the nurse consider when client 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 nurse finds a radial pulse that is weak and thready. What action should the nurse take next?

Palpate the carotid arteries Explanation: A weak and thready pulse is abnormal and the nurse should assess the carotid pulses because they are the best assessment of contour and amplitude. This is due to their proximity to the heart and the pulse wave of the carotid pulse coincides closely with ventricular systole.

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 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.

A client rates the current pain level as being a 5 on the Numeric Rating Scale. How should the nurse document this pain assessment?

Patient rated pain level as being a 5 using the rating scale. Explanation: The nurse should document the exact pain assessment finding which would be "client rated pain level as being a 5 using the rating scale." The statement "client experiencing a moderate amount of pain" is a subjective statement made by the nurse and is inaccurate. The statement "client experiencing mild pain" is a subjective statement made by the nurse and is inaccurate. The statement "client stated pain level not that bad" is a subjective statement made by the client however does not identify that the client rated the pain level as being a 5 on the Numeric Rating Scale.

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.

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. 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.

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

Reading will be high Explanation: If the blood pressure cuff used is too small and the client's arm is large, the blood pressure reading will be high. If the blood pressure cuff is too large and the client'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 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 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.

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.

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

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.

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. 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 assessing a client who has a fever, has an infection of a flank incision, and is in severe pain. What type of pulse rate would be likely?

Tachycardia Explanation: The pulse rate increases (tachycardia) and decreases in response to a variety of physiologic mechanisms. Tachycardia is a response to an elevated body temperature and pain.

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

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.

An adult client with a body mass index of 16 experiences dizziness. Click on the image to identify the cuff that the nurse should use to measure this client's blood pressure.

The adult client is underweight and most likely has thin limbs. A smaller blood pressure cuff will most likely provide the most accurate measurement. Using the regular adult size or oversized cuff will provide falsely low blood pressure readings.

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.

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. Explanation: Several factors may cause normal variations in the core body temperature. Strenuous exercise, stress, and ovulation can raise temperature. Body temperature is lowest early in the morning (4:00 to 6:00AM) and highest late in the evening (8:00PM to midnight). Hypothermia (lower than 36.5ËC or 96.0ËF) may be seen in prolonged exposure to the cold, hypoglycemia, hypothyroidism, or starvation. Hyperthermia (higher than 38.0ËC or 100ËF) may be seen in viral or bacterial infections; malignancies; trauma; and various blood, endocrine, and immune disorders.

A client, sipping hot tea, is scheduled for routine vital signs. Which illustration shows the least appropriate method for the nurse to use to obtain an accurate temperature reading?

The oral temperature would give a falsely elevated reading because the client is sipping hot tea. The axillary temperature will take the longest to register, but would not be affected by the client's tea consumption. Both the tympanic and temporal artery methods are considered safe, reliable, and noninvasive and either would be most appropriate to use.

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

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 blood pressure of a client using the Korotkoff's sounds technique. The nurse notes that the phase I sound disappears for 2 seconds. What should the nurse document on the progress record?

There is an auscultatory gap Explanation: An auscultatory gap is a period during which sound disappears. An auscultatory gap can range as much as 40 mm Hg. A widening in the diameter of the artery takes place in the phase II of the Korotkoff's sounds technique. An adult diastolic pressure takes place in the phase IV of the Korotkoff's sounds technique.

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?

Thready pulse Explanation: 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.

What is the importance of assessing vital signs? (Select all that apply.)

To establish a baseline To monitor risks for alterations in health To evaluate the client's responses to treatment Explanation: 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. Vital signs are not assessed to carry out orders from the healthcare provider or to plan how to improve a client's condition.

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 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.

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

Tympanic Explanation: The tympanic temperature is a good device for measuring core body temperature because it measures temperature quickly and safely. The tympanic membrane is supplied by a tributary of the artery (internal carotid) that supplies the hypothalamus (the body's thermoregulatory center). Oral is the most commonly used because it is the easiest to obtain. Axillary temperature is usually about 0.5°F to 1.0° F below the oral temperature. Rectal readings are often 0.4°F to 0.5°F higher than the oral temperature.

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.

A client is concerned that a blood pressure reading of 180/78 mm Hg is extremely high when the readings usually are around 130/60 mm Hg. What could have caused this elevation in blood pressure?

arm below the level of the heart Explanation: One reason for a falsely elevated blood pressure is the arm being held below the level of the heart. Reasons for a false low blood pressure include a cuff that is too large, deflating the cuff too quickly, and not placing the stethoscope over the brachial artery.

A client's blood pressure is affected by

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).

An elderly client is seen by the nurse in the neighborhood clinic. The nurse observes that the client is dressed in several layers of clothing, although the temperature is warm outside. The nurse suspects that the client's cold intolerance is a result of

decreased body metabolism. Explanation: Research has shown that for older adults, normal body temperature values for all routes are consistently lower than values reported in younger populations.

A client is wearing a hospital gown and sitting on the examination table. What area should the nurse include when completing the general survey?

facial expression Explanation: The general survey provides an overall impression of the client and includes facial expression. Pulse rate is palpated and would occur later in the examination. Breath sounds are auscultated and would occur later in the examination. Skin temperature is palpated and would occur later in the examination.

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

kyphosis Explanation: In older adults, osteoporotic thinning and collapse of the vertebrae secondary to bone loss may result in kyphosis.

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

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 nurse is preparing to assess the respirations of an alert adult client. The nurse should

observe for equal bilateral chest expansion of 2.54 to 5.08 cm (1 to 2 in). Explanation: When observing respiratory depth the nurse should assess for equal bilateral chest expansion of 1 to 2 inches.

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

oral: 36.8°C Explanation: Normal values for temperature fall within a range. Normal values for an oral temperature are around 36.8°C, a rectal temperature around 37.1°C, an axillary temperature around 36.0°C, and a tympanic temperature around 37.0°C.

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.

What information concerning a client's respirations should the nurse record after completing a general physical assessment?

rate, rhythm, and depth of respirations taken for a full minute Explanation: Recording the rate, rhythm, and depth is important after the assessment. While the other information is relevant, it is not considered a part of the general physical assessment.

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. Explanation: Validate the assessment data you have collected. This is necessary to verify that the data are reliable and accurate. Document the assessment data following the health care facility or agency policy.

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.