Chapter 24: Vital Signs : Questions from "The Point"

Which of the following patient variables have the potential to result in either short term or longer term increases in blood pressure?

-Older age. -African American race -Obesity

The nursing student is selecting a blood pressure cuff prior to obtaining a patient's blood pressure. What cuff width is appropriate to obtain an accurate blood pressure reading?

40% of the circumference of the limb to be used.

Upon auscultation of a patient's heart rate, the nurse notes the rate to have an irregular pattern of 72 beats/min. The nurse notifies the physician because the patient is exhibiting signs of which of the following?

A dysrhythmia.

An 86-year-old male patient 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 patient 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 patient's temperature by axilla.

An obese patient has developed peripheral edema as as consequence of heart failure, making it very difficult for the student nurse to accurately palpate the patient's peripheral pulses. How should the nurse proceed with this assessment?

Auscultate the patient's apical pulse.

What site of pulse assessment is used during an emergency assessment for an adult patient?

Carotid pulse.

Which of the following conditions will lead to an increase in cardiac output?

Exercise.

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

Increased pulse rate.

During a busy shift, Nurse R. admitted a postsurgical patient who is obese. Nurse R. used the standard size of blood pressure cuff available on the unit, despite the fact that the patient's upper arms have a high circumference. What are the potential consequences of Nurse R.'s action?

Nurse R. may obtain a blood pressure reading that is higher than actual blood pressure.

The nurse places a patient in experiences labored breathing in an upright position. The nurse notes that the patient is able to breathe more easily in this upright position and documents this condition on the chart as which of the following?

Orthopnea.

A nurse is filing 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.

Nurse T. has auscultated Mr. Weinstein's apical pulse while a colleague simultaneously palpated his radial pulse. This assessment of Mr. Weinstein's apical-radial pulse indicates that the two values differ signifigantly, a finding that suggests which of the following health problems?

Peripheral vascular disease.

When assessing a patient's vital signs, a nursing student has explained each of her next actions prior to assessing the patient's temperature, pulse, and blood pressure, but has not announced her intention to assess the patient's respiratory rate prior to measuring it. Which of the following is a plausible rationale for the nurse's decision?

Respirations have both autonomic and voluntary control.

What organ is the primary site of heat loss in the body?

Skin

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 notes a difference in systolic blood pressure readings between the patient's arms. How will the nurse approach subsequent readings based upon this difference in blood pressures?

The nurse will use the arm with the highest reading.

A nurse who provides care on a hospital unit has taken a patient's temperature this morning, yielding a reading of 37.6 C (99.7F) How should the nurse best interpret this assessment finding?

This body temperature may temporarily enhance the patient's immune function.

Which of the following sites results in measuring a patient's core body temperature?

Tympanic