EAQ - Chapter 10 - Vital Signs

Which statement by the nursing student indicates effective learning about blood pressure cuff sizes?

"A cuff size too narrow for a patient will give a false high blood pressure (BP)."

Which statement about taking oral temperatures is correct?

"Drinking hot liquids may alter the temperature reading."

Which finding would the nurse consider abnormal when obtaining the heart rate of a 20-year-old patient who runs marathons?

105 beats per minute

Which respiratory rate is normal for a 9-year-old patient?

22 breaths per minute

At which age would the nurse begin routine monitoring of blood pressure in children at low risk for hypertension?

3 years

The nurse determines the pedal pulses of a patient to be full and bounding. How would the nurse document this finding?

3+

The patient's blood pressure is 120/74 mm Hg and heart rate is 80 beats per minute. Which number would the nurse record as the pulse pressure?

46 Rationale: Pulse pressure is the difference between systolic and diastolic pressures. This number reflects the stroke volume. For a patient with a blood pressure of 120/74 mm Hg and a heart rate of 80 bpm, the equation to find pulse pressure would be: 120 - 74 = 46. The diastolic blood pressure is 74. The heart rate is 80. The systolic blood pressure is 120. p. 144

The nurse counts the pulse of a patient with an irregular heart rate for how many seconds?

60

Which describes orthostatic hypotension?

A decrease in blood pressure moving from supine to standing positions

Which factors directly affect blood pressure? Select all that apply.

Age Race Sex Stress level

The nurse measures the oral temperature of a patient and then learns the patient just drank a cup of iced coffee. Which action by the nurse is appropriate?

Asking the patient to return to the clinic in 15 minutes and to refrain from drinking anything

The patient with a history of hypertension has a standing blood pressure of 90/60 mm Hg. Which intervention would the nurse perform first?

Assess the blood pressure again.

Which factors acutely affect blood pressure? Select all that apply.

Blood viscosity Cardiac output Peripheral vascular disease

A decrease in which characteristic is responsible for hypotension after an acute myocardial infarction?

Cardiac output

Which is an appropriate step to take before assessing a patient's blood pressure?

Check that the patient's feet are flat on the floor.

Which manner of counting would the nurse use to assess the respiratory rate of a patient with shallow breathing?

Count for a full 60 seconds straight

The nurse attempts to determine the patient's oxygen saturation level, but the pulse oximeter is not providing a reading. Which assessment finding is likely the cause of the error?

Dark nail polishLow blood pressure Rationale: Dark nail polish can prevent accurate readings for pulse oximetry. Hypothermia, vasoconstriction as with hypertension, and low hemoglobin cause inaccurate readings.

Which action by the nurse during a blood pressure assessment will lead to a falsely high diastolic reading?

Deflating blood pressure cuff too slowly Rationale: A falsely high diastolic reading can occur when the blood pressure cuff is deflated too slowly. Inflating the blood pressure cuff too high, pushing the stethoscope too hard on the brachial artery, and failing to palpate the radial artery during inflation can cause falsely low blood pressure readings, not falsely high readings.

The patient with no history of hypertension has a blood pressure reading of 190/100 mm Hg. Which action by the nurse is appropriate?

Determine appropriate cuff size

Which clinical manifestation reported by the patient would lead the nurse to obtain orthostatic blood pressure readings?

Dizziness with position changes

Which nursing intervention will help the nurse accurately measure respiratory rate in an obese patient?

Feel the breaths by placing a hand on the patient's abdomen.

The pulse of a patient with acute anxiety would have which characteristic?

Full and bounding

When auscultating the blood pressure of a 2-year-old patient, which is most important for the nurse to perform to obtain an accurate measurement?

Have child seated 5 minutes before auscultation

Which condition would the nurse suspect in a patient with consistent blood pressure readings averaging 160/90 mm Hg?

Hypertension

Which symptoms are expected in a patient suffering from an acute myocardial infarction? Select all that apply.

Hypotension Cool, clammy skin Shoulder and jaw pain

Which organ is considered the thermostat of the human body?

Hypothalamus

Which phase of the Korotkoff sounds is documented as the systolic blood pressure reading?

I RationaleThe first (I) sound heard as the blood pressure cuff begins to deflate is the first Korotkoff sound, which indicates systolic blood pressure. The second phase (II) is a swooshing sound of turbulent blood flow through a still partially occluded artery. The third (III) sound is a knocking sound of longer duration of blood flow through the artery. The fourth (IV) sound is an abrupt muffling sound that occurs when the artery no longer closes in any part of the cardiac cycle.

Which physiologic changes result in hypertension? Select all that apply.

Increased blood volume Increased vasoconstriction

The nurse measures the blood pressure of a supine patient at 110/70 mm Hg. When the patient stands, the nurse immediately finds the blood pressure to be 90/70 mm Hg. The nurse explains these results to the patient using which pathophysiology?

Increased peripheral vasodilation Rationale: The abrupt peripheral vasodilation decreases the force of blood flow in the blood vessels of the patient and thus results in hypotension. The sudden drop in blood pressure due to position change indicates orthostatic hypotension in the patient, and it usually occurs with aging, bed rest, and hypovolemia. A change in the position does not bring any alteration in the cardiac output of the patient. Increased rigidity and peripheral vascular resistance of the blood vessel walls do not decrease the blood pressure; instead, they increase the blood pressure of the patient. p. 150

Which conditions may cause hyperthermia in a patient? Select all that apply.

Infection Cerebral trauma Myocardial infarction

The nurse is measuring a patient's thigh blood pressure (BP). Which is the most important point that the nurse should remember about thigh pressure?

It is higher than in the arm.

Which vital sign change is expected in an older adult?

More easily palpable pulse

Which action would the nurse perform before initially inflating the cuff during a blood pressure assessment?

Palpate the brachial artery

Which action by the student nurse measuring blood pressure requires further teaching?

Pausing during descent and reinflating the cuff

Which vital sign will the nurse assess first in the patient with a history of cardiac dysrhythmias?

Pulse

Which route would the nurse use to assess temperature with an electronic thermometer with a red-tipped probe?

Rectal

The neonate has a respiratory rate of 64 breaths per minute. The nurse uses which term to document this finding?

Tachypnea RationaleThe neonate with tachypnea may have a respiratory rate of more than 60 breaths per minute. The normal respiratory rate in the neonate is in the range of 30 to 60 breaths per minute, which is considered eupnea. A respiratory rate below 30 breaths per minute in the neonate is considered bradypnea. Apnea indicates zero respirations.

Which type of Korotkoff sound would the nurse correlate with the systolic blood pressure?

Tapping sounds

Which vital sign in a healthy 90-year-old patient is likely as a result of the aging process?

Temperature 95.8°F

The blood pressure taken in which location will be the highest in the patient with coarctation of the aorta?

Upper arm RationaleNormally the thigh blood pressure is higher than in the arm, but a patient with coarctation of the aorta will have a lower thigh blood pressure due to constriction of the blood supply. The upper arm will provide the highest blood pressure reading, not the calf, thigh, or forearm.

Which findings would the nurse expect in the patient with hemorrhagic shock? Select all that apply.

Weak, thready pulse Decreased blood volume Decreased stroke volume

Which thermometer can measure the oral temperature of a child within 25 seconds?

he electronic thermometer with a blue-tipped probe RationaleThe electronic thermometer with a blue-tipped probe measures oral temperature within 20 to 30 seconds. The glass thermometer measures oral temperature within 2 to 3 minutes, not within 25 seconds. The tympanic membrane thermometer records temperature by detecting infrared radiation from the tympanic membrane and, therefore, does not help measure oral temperature. The temporal artery thermometer detects infrared emissions from the temporal artery thereby recording the temperature; it does not detect oral temperature. p. 140