Chapter 30: Vital Signs (Vital Signs)

What is the acceptable axillary temperature for adults?

*A. 36.5° C (97.7° F)* B. 37° C (98.6° F) C. 37.1° C (98.8° F) D. 37.5° C (99.5° F) Rationale: The average axillary temperature for adults is 36.5° (97.7°). The average oral and tympanic temperature is 37°C (98.6°F). The acceptable range of body temperature of adults is 36-38°C (96.6-100.4°F). The average rectal temperature is 37.5°C (99.5°F). Pg. 487

Which site is preferred for assessing the heart rate in a patient?

A. Apical *B. Radial* C. Carotid D. Temporal Rationale: The radial site is used to assess the status of circulation and is the preferred site when assessing the heart rate in a patient. The carotid site is present in the neck along the medial edge of the sternocleidomastoid muscle. The pulse rate is assessed from the carotid site when other sites are not palpable in a patient with cardiac arrest. The apical site is used to assess apical pulse rate. The temporal site is used to assess pulse rate in children. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. Pg. 498

Which patient needs medical attention? Vital Signs-------------pt A------pt B------pt C------Pt D Pulse Rate--------------82--------76--------50--------98 (beats/minute) Pulse Oximetry(%)-----99--------95--------93--------97

A. Patient A B. Patient B *C. Patient C* D. Patient D Rationale: The normal range of pulse rate in an adult is 60 to 100 beats per minute. Therefore, patient C with the pulse rate of 50 beats per minute has an abnormal reading. The normal range of pulse oximetry in an adult is SpO 2 ≥ 95%. Again, patient C, with 93%, has an abnormal reading and requires medical attention. The measurements for patients A, B, and D are normal. Pg. 487

What are reasons the nurse would have difficulty identifying a probe site for a pulse oximeter in older patients? Select all that apply.

*A. Anemia* B. Tachypnea C. Loss of upper arm mass *D. Decreased cardiac output* *E. Cold-induced vasoconstriction* Rationale: In older adults, it may be difficult to identify an acceptable pulse oximeter probe site due to anemia, decreased cardiac output, and cold-induced vasoconstriction. Tachypnea may result from subtle changes in the temperature. The loss of upper arm mass would require selecting a smaller size blood pressure cuff. Pg. 511

The registered nurse is teaching a nursing student about measuring vital signs. Which statements by the nursing student indicate a need for further learning? Select all that apply.

A. "I should measure vital signs before, during, and after transfusion of blood products." B. "I should measure vital signs of a patient during home care visits." *C. "I should measure vital signs after the intensity of pain decreases in the patient."* *D. "I should measure vital signs after the patient performs range of motion exercises."* E. "I should measure vital signs when the general physical condition changes." Rationale: Vital signs should be measured in a patient when the intensity of pain increases. Vital signs should be measured before the patient performs range of motion exercises. Vital signs can be measured before, during, and, after transfusion of blood products. Vital signs can be measured while assessing a patient during home care visits. Vital signs should be measured when the patient's physical condition changes. Pg. 487

What is the acceptable tympanic body temperature for adults?

A. 36° C (96.8° F) B. 36.5° C (97.7° F) *C. 37° C (98.6° F)* D. 37.5° C (99.5° F) Rationale: The average tympanic temperature for adults is 37° C (98.6° F). A body temperature of 96.8° F is within the normal range for adults. The average axillary temperature for adults is 36.5° C (97.7° F). The average rectal temperature for adults is 37.5° C (99.5° F). Pg. 487

The registered nurse is teaching a nursing student about the guidelines for measuring vital signs. Which statement by the nursing student indicates the need for further learning? Select all that apply.

A. "I can interpret the significance of vital sign data." *B. "I can use an adult-size blood pressure cuff on a 7-year-old child."* C. "I can make decisions about required interventions based on the data." D. "I can assess the equipment to ensure that it provides accurate findings." *E. "I can delegate the measurement of vital signs if the patient's condition is critical."* Rationale: The nurse should select the equipment based on the patient's condition and characteristics. The adult size blood pressure (BP) cuff should not be used for a 7-year-old child because it may give false results. The nurse should delegate the measurement of vital signs only in certain situations, when the condition of the patient is stable. It is the responsibility of the nurse to review vital sign data and interpret their significance. The nurse should critically think through the decisions about required interventions based on vital sign data. The nurse should assess the equipment regularly to ensure that it is working correctly and provides accurate findings. Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or patient. All options likely relate to the situation, but only some of the options may relate directly to the situation. Pg. 487

The registered nurse is teaching a nursing student about the guidelines for measuring vital signs. Which statements by the nursing student indicate the need for further teaching? Select all that apply.

A. "I should know the patient's medical history." *B. "I should analyze the results of vital signs compared with other patients."* *C. "I should measure the body temperature in a humid environment."* D. "I should know the acceptable range for the patient before giving medications." E. "I should use vital sign measurement to determine indications for giving medication." Rationale: The nurse should analyze the results of vital sign measurement on the basis of the patient's condition and past medical history and not compared to other patients. The nurse should not measure vital signs in a humid environment, because the humidity may affect the vital signs. The nurse should know the patient's medical history. The nurse should know the acceptable range for the patient before giving medications. The nurse should use vital sign measurement to determine indications for giving medication. Pg. 487

The registered nurse is teaching a nursing student about the assessment of vital signs in older adults. Which statement by the nursing student indicates the need for further teaching?

*A. "I should use a large cuff to measure blood pressure."* B. "I should instruct the patient to slowly change his or her position." C. "I should assess the skin while frequently monitoring the blood pressure." D. "I should rotate the sites for measurement of blood pressure for frequent monitoring of blood pressure." Rationale: Older adults usually lose upper arm mass and require a smaller blood pressure cuff. Changing the patient's position will help reduce the risk of postural hypotension. The skin of older adults is more fragile and susceptible to cuff pressure during frequent measurements. Therefore, it is advised to make frequently assess the skin under the cuff and rotate blood pressure sites. Pg. 511

For which type of patient would the nurse use a Doppler device to obtain an accurate reading?

*A. A patient with obesity* B. A patient with scoliosis C. A patient with a rigid rib cage D. A patient with poor muscle control Rationale: A Doppler device is used to obtain an accurate pulse rate for an obese patient. There could be difficulty palpating the pulse of the patient with obesity. Therefore, to get an accurate reading, the Doppler device is used. Scoliosis may restrict the patient's chest expansion and decrease tidal volume. A patient with a rigid rib cage may have reduced chest wall expansion. Poor muscle control may affect the reading of oral temperature. However, these conditions would not require the use of a Doppler device to obtain an accurate pulse reading. Pg. 511

As a registered nurse (RN) caring for a 60-year-old patient with complaints of dyspnea, cough, and sweating, it is important to monitor the patient's vital signs. In which situations must the nurse measure the vital signs? Select all that apply.

*A. According to the needs of the patient* *B. On admission to the hospital* C. While the patient is sleeping *D. Before and after the patient complains of distress* *E. Before and after the patient receives a respiratory treatment* Rationale: Vital signs should be taken as often as the patient's condition warrants and according to the needs of the patient. It is important to measure the vital signs of the patient on admission to the hospital to determine the baseline vital signs. Vital signs should also be checked any time the patient complains of any distress. There is no major change in vital signs during sleep, so recording at that time is not required. Vital signs are always taken and recorded before and after any medication that could affect the patient's pulmonary, respiratory function, or other vital signs. Pg. 487

Which action should the nurse perform immediately after finding abnormal vital sign values in a patient who underwent abdominal surgery?

*A. Asking another nurse to repeat the measurement* B. Informing the primary health care provider C. Documenting the finding in the patient record D. Reporting vital sign change to nurses during hand-off communication Rationale: If the nurse finds abnormal vital signs in a patient, he or she should immediately ask another nurse or the primary health care provider to repeat the measurements to confirm the findings. After confirming the findings, the nurse should inform the primary health care provider, document the finding in the patient record, and report vital sign changes to nurses during hand-off communication. Pg. 487

While assessing the respiration of an older adult, the nurse finds it difficult to identify an acceptable site for placement of pulse oximeter probe. What would be the reason for this difficulty?

*A. Decreased cardiac output* B. Increase in body temperature C. Decrease in sweat gland reactivity D. Abnormal lateral curvature of the spine Rationale: When there is decreased in cardiac output, the nurse may find it difficult to identify an acceptable site for placement of the pulse oximeter probe. A decrease in sweat gland reactivity in the older adult results in a higher threshold for sweating at high temperatures, which can lead to hyperthermia and heart stroke. Abnormal lateral curvature of the spine in older adults causes restriction of chest expansion and decrease in tidal volume. Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem of the item that are the same or similar in nature to those in one or two of the options. Pg. 511

Which statements are true regarding the factors affecting vital signs of older adults? Select all that apply.

*A. It is important to pay attention to subtle temperature changes in older adults.* *B. Older adults are very sensitive to slight changes in environmental temperature.* *C. A decrease in sweat gland reactivity in older adults may lead to hyperthermia.* D. The oral site is best for taking accurate temperature readings in older adults. E. The temperature of the older adult is at the upper end of the normal temperature range. Rationale: It is important to be attentive to subtle temperature changes and other manifestations of fever in older adults. Older adults are very sensitive to slight changes in environmental temperature, because their thermoregulatory systems are not as efficient. A decrease in sweat gland reactivity in the older adults results in a higher threshold for sweating at high temperatures that leads to hyperthermia and heatstroke. Older adults are often missing teeth and have poor muscle control; therefore, they may be unable to close their mouth tightly to obtain accurate oral temperature readings. The temperature of older adults is at the lower end of the normal temperature range. Pg. 511

The nurse measures the vital signs of four different adults. Which patient has abnormal findings? Vital Signs------pt 1--------pt 2--------pt 3--------pt 4 Pulse pressure-----28mmHg--34mmHg--48mmHg--40mmHg Respir.-----------8-----------16----------12----------18 Pulse------------48---------80----------68---------75 Capnography---30---------36---------40----------44 (EtCO2)

*A. Patient 1* B. Patient 2 C. Patient 3 D. Patient 4 Rationale: The acceptable range of pulse pressure of an adult is 30 to 50 mm Hg. The normal rate of respiration of an adult is 12 to 20 breaths/minute. Normal respirations are deep and regular. A strong and regular pulse is in the range of 60 to 100 beats per minute. The normal range of capnography (EtCO 2) in an adult is 35 to 45 mm Hg. Therefore, the patient with a pulse pressure of 28 mm Hg, respiratory rate of 8 breaths/minute, pulse of 48 beats/minute, and capnography measurement of 30 mm Hg has abnormal findings. The vital signs of the other patients are normal. Pg. 511

The nurse decides not to measure the temperature of an older adult using the oral site. What is the likely reason for this decision? Select all that apply.

*A. Patient has no teeth* B. Patient has a rigid rib cage *C. Patient has poor muscle control* D. Patient's ribs are downward-slanted E. Patient's sweat gland reactivity is decreased Rationale: The oral temperature for older adults may be inaccurate due to an inability to close the mouth completely, which may occur due to the absence of teeth and poor muscle control. The rigidity of the rib cage may cause chest wall expansion. The patient with downward-slanted ribs may have restricted chest expansion and decreased tidal volume. A patient with decreased sweat gland reactivity may suffer hyperthermia and heat stroke. Pg. 511

Which vital values in a patient are abnormal? Select all that apply.

*A. Pulse oximetry 92%* *B. Pulse pressure 60 mm Hg* C. Axillary temperature 97.7° F D. Pulse rate 80 beats per minute E. Respiratory rate 18 breaths per minute Rationale: The normal range of pulse oximetry in an adult is SpO 2 ≥ 95%; therefore, a pulse oximetry value of 92% is low. The normal range of pulse pressure in an adult is 30-50 mm Hg; therefore, a pulse pressure value of 60 mm Hg is high. The average axillary temperature in a normal adult is 36.5° C (97.7° F). The normal range of pulse rate in an adult is 60-100 beats per minute. The normal range of respiratory rate in an adult is 12-20 breaths per minute. Pg. 487

Which statements are true regarding blood pressure in older adults? Select all that apply.

*A. The skin should be assessed at the blood pressure cuff.* B. In frail older adults, a larger size blood pressure cuff is used for assessing. *C. Increasing systolic pressure will result in wider pulse pressure.* D. Decreased systolic pressure is caused by decreased vessel elasticity. *E. The older adult is instructed to change position slowly to prevent hypotension.* Rationale: In older adults, the skin is assessed at the blood pressure cuff. Wide pulse pressure in older adults results from increasing systolic blood pressure with constant systolic blood pressure. Older adults are instructed to change position slowly to prevent hypotension. In frail older adults, a smaller size blood pressure cuff is used, not a larger cuff. In older adults, increased systolic pressure is caused by decreased vessel elasticity. Pg. 511

The nurse is assessing the vital signs for a patient who underwent lung surgery. The nurse observes differences in the vital signs as compared to the values recorded before the surgery. What should be the immediate action of the nurse in this situation?

*A. Writing a variance note* B. Providing required medications C. Documenting nursing interventions D. Making required environmental changes Rationale: When the vital signs show differences after surgery, the nurse should immediately write a variance note to explain the nature of variance and the nursing course of action. The nurse should provide prescribed medications to treat the patient, but this would not be an immediate intervention.Nursing interventions should be documented when the interventions are initiated, such as when oxygen therapy or antihypertensive medication is administered. The nurse may make required environmental changes to provide comfort to the patient, but this would not be an immediate action. Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable under ordinary circumstances and that the action can be carried out in the given situation. Pg. 510

The registered nurse teaches the student nurse about the correct times to measure vital signs. Which statement by the student nurse shows ineffective learning?

A. "I will assess the vital signs during home care visits." B. "I will assess the vital signs before, during, and after a surgical procedure." C. "I will assess the vital signs of a patient who reports nonspecific symptoms of physical distress." *D. "I will assess the vital signs every hour when the physical condition of the patient worsens."* Rationale: Vital signs are the rapid and efficient way of monitoring a patient's condition. These signs help to identify problems and to evaluate the patient's response to interventions. The nurse is responsible for judging the frequency of assessment of these signs. The nurse should measure vital signs every five to 10 minutes when the physical condition of the patient worsens.The nurse should measure vital signs during home care visits. The vital signs should also be monitored before, during, and after a surgical procedure. When a patient reports nonspecific symptoms of physical distress, the nurse should assess the vital signs. Pg. 487

The registered nurse is teaching a nursing student about the vital parameters for older adults. Which statements by the nursing student indicate a need for further teaching? Select all that apply.

A. "Older adults are easily susceptible to heat stroke." *B. "Accurate oral temperature can be obtained in edentulous patients."* C. "Lowered sweat gland activity may cause hyperthermia in older adults." *D. "Older adults are less sensitive to changes in environmental temperature."* E. "Temperatures considered normal in a young patient may indicate fever in an older adult." Rationale: Accurate oral temperatures cannot be measured in edentulous patients and patients with poor muscle control due to their inability to close the mouth completely. A compromised thermoregulatory system in older adults results in increased sensitivity to minute changes in environmental temperatures. Heat stroke and hyperthermia occurs in older adults as a result of decreased reactivity of sweat gland to higher temperatures. The temperature of older adults is at the lower end of the normal temperature range. Therefore, temperatures considered within normal range sometimes reflect a fever in an older adult. Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or patient. All options likely relate to the situation, but only some of the options may relate directly to the situation. Pg. 511

The nurse is teaching the nursing student about when to measure the vital signs in a patient. Which statement by the nursing student indicates the need for further learning? Select all that apply.

A. "Vital signs should be measured before ambulating a patient previously on bed rest." *B. "Vital signs should be measured before and after a transfusion of blood products."* C. "Vital signs should be measured after a patient reports increased intensity of pain." D. "Vital signs should be measured before a patient performs range-of-motion exercises." *E. "Vital signs should be measured after the administration of medication that affects temperature control functions."* Rationale: Vital signs should be measured before, during, and after a transfusion of blood products, not only before and after. During the blood transfusion, it is important to measure vital signs to check the occurrence of any complication due to transfusion rate or amount of blood product transfusion. Vital signs should be measured before, during, and after the administration of medication that affects temperature control functions, not only after. Before the administration of medication that affects temperature control, it is important to measure vital signs to determine whether the patient is really in need of that medication. During the administration of medication that affects temperature control, it is important to measure the vital signs to check for overdosing. Vital signs should be measured before a patient previously on the bed ambulates. Vital signs should be measured after a patient reports increased intensity of pain. Vital signs should be measured before a patient performs range-of-motion exercises. Pg. 487

The nurse is measuring the vital signs of a patient. What is the normal range of pulse pressure?

A. 10 to 15 mm Hg B. 20 to 25 mm Hg *C. 30 to 50 mm Hg* D. 60 to 70 mm Hg Rationale: Pulse pressure is defined as the difference between the systolic and diastolic blood pressure normally ranging from 30 to 50 mm Hg. Any value below 30 mm of Hg and above 50 mm of Hg is considered to be outside the normal range. Test-Taking Tip: Recall that normal blood pressure is considered to be less than 120/80. The pulse pressure for this measurement = 40, giving you the correct answer to this question. Pg. 503

Which value indicates normal pulse pressure?

A. 28 mm Hg *B. 36 mm Hg* C. 78 mm Hg D. 119 mm Hg Rationale: The normal pulse pressure of an adult is 30 to 50 mm Hg. Therefore, 36 mm Hg is the normal finding. A pulse pressure value less than 30 indicates an abnormality. Therefore, 28 mm Hg is not normal. The normal diastolic blood pressure is less than 80 mm Hg. Therefore, 78 mm Hg is a normal diastolic blood pressure value but is well above the range for normal pulse pressure. The normal systolic blood pressure is less than 120 mm Hg. Therefore, 119 mm Hg is a normal systolic blood pressure value but is well above the range for normal pulse pressure. Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses. Pg. 487

What is the average rectal temperature for adults?

A. 36.5° C (97.7° F) B. 37° C (98.6° F) *C. 37.5° C (99.5° F)* D. 38° C (100.4° F) Rationale: The average rectal temperature for an adult is 37.5° C (99.5° F). The average axillary temperature is 36.5° C (97.7° F). The average oral/tympanic temperature is 37° C (98.6° F). A single oral temperature of 38° C (100.4° F) would indicate fever in older patients. Pg. 487

What is the average rectal temperature of a 35-year-old adult?

A. 36.5° C (97.7° F) B. 37° C (98.6° F) *C. 37.5° C (99.5° F)* D. 38° C (100.4° F) Rationale:The average rectal temperature of adults is 99.5° F. The axillary temperature of adults is 97.7° F. The average oral or tympanic temperature of adults is 98.6° F. Normal temperature range is between 96.8 and 100.4° F. Pg. 487

Which symptom is associated with an elevated temperature?

A. Cyanosis B. Chest pain *C. Diaphoresis* D. Shortness of breath Rationale: Along with the actual vital signs, there will be symptoms accompanied with it. Elevated body temperature results in diaphoresis. Cyanosis is associated with hypoxemia. Chest pain occurs due to abnormal blood pressure. Abnormal respirations result in shortness of breath. Pg. 510

Which conditions may result from decreased sweat gland reactivity in an older patient? Select all that apply.

A. Delirium B. Anorexia C. Tachypnea *D. Heatstroke* *E. Hyperthermia* Rationale: A decrease in sweat gland reactivity in an older adult may result in a higher threshold for sweating at high temperatures, which may lead to hyperthermia and heatstroke. Various manifestations such as tachypnea, anorexia, falls, delirium, and overall functional decline are mainly associated with subtle temperature changes or fever. Pg. 511

A nurse is assessing the vital signs and other parameters of an 80-year-old patient. The details of the examination are given below. Which parameter can be considered abnormal in the patient? Assessment Parameter-------Observation Made Heart sounds-----------------Muffled heart sounds Blood pressure---------------Decreased systolic B/P Body Temperature------------Slightly less than normal Heart rate at rest--------------Decreased heart rate

A. Heart sounds *B. Blood pressure* C. Heart rate at rest D. Body temperature Rationale: Decreased vessel elasticity usually results in increased systolic pressure in older adults. Heart sounds are sometimes muffled or difficult to hear in older adults because of an increase in air space in the lungs. The older adult has a decreased heart rate at rest. The normal body temperature of older adults is lower than the body temperature of a younger adult. Pg. 511

A nurse is assessing the vital signs and other parameters of an 80-year-old patient. The details of the examination are given below. Which parameter can be considered abnormal in the patient? Assessment Parameter-------Observation Made Heart sounds---------------- Muffled heart sounds Blood pressure-------------- Decreased systolic B/P Body Temperature -----------Slightly less than normal Heart rate at rest ------------Decreased heart rate

A. Heart sounds *B. Blood pressure* C. Heart rate at rest D. Body temperature Rationale: Decreased vessel elasticity usually results in increased systolic pressure in older adults. Heart sounds are sometimes muffled or difficult to hear in older adults because of an increase in air space in the lungs. The older adult has a decreased heart rate at rest. The normal body temperature of older adults is lower than the body temperature of a younger adult. Pg. 511

While assessing the pulse rate of an 80-year-old patient, the nurse has difficulty hearing the heart sounds of the patient. What could be the reason for the muffled heart sounds?

A. Increased heart rate B. Decreased vessel elasticity *C. Increased air space in lungs* D. Ossification of costal cartilage Rationale: Heart sounds maybe muffled or difficult to hear in older adults due to an increase in air space in the lungs. An increase in heart rate would show differences in pulse rate, not differences in heart sounds. Older adults may experience an increase in systolic pressure due to decreased vessel elasticity. Ossification of costal cartilage for older adults results in reduced chest wall expansion. Test-Taking Tip: Read the question carefully before looking at the answers: (1) Determine what the question is really asking, andlook for key words; (2) read each answer thoroughly, and see if it completely covers the material the question asks; and(3) Narrow the choices by immediately eliminating answers you know are incorrect. Pg. 511

A 60-year-old male patient complains of severe breathlessness, sweating, pain in the chest, and cough. What guidelines should the nurse follow when measuring the vital signs? Select all that apply.

A. Measure the vital signs four times per day. *B. Determine the patient's medical history.* *C. Use equipment that is appropriate per the age of the patient.* D. Report all changes in vital signs to the health care provider. *E. Use vital sign measurements to determine indications for medication administration.* Rationale: The nurse should know the patient's medical history to know which vital signs would be affected by medications, environmental factors, or the ability to detect complications. Proper equipment per the age of the patient should be used to prevent errors. The vital signs should be used as an indicator for administration of medication. For example, certain cardiac drugs would be used only within a range of pulse of blood pressure values. The frequency of measuring the vital signs has to be discussed with the primary health care provider. It is not necessary to immediately report changes in the vital signs to the healthcare provider unless the change is significant. Pg. 487

The nurse is working in a surgical unit. When should the nurse measure vital signs? Select all that apply.

A. Only after a surgical procedure B. Only after a blood transfusion *C. Before and after a surgical procedure* *D. Before and after a blood transfusion* *E. Before a patient performs range-of-motion exercises* *F. After a patient performs range-of-motion exercises* Rationale: The nurse is responsible for judging when to measure vital signs. Some of the situations when vital signs should be measured include before and after any surgical or invasive diagnostic procedure, before and after blood transfusions, and before and after an intervention that can influence vital signs, such as when a patient performs range-of-motion exercises. Test-Taking Tip: Key words or phrases in the stem of the question such as first, primary, early, or best are important. Similarly, words such as only, always, never, and all in the alternatives are frequently evidence of a wrong response. For this question, the two choices that contain the word only are both incorrect. As in life, no real absolutes exist in nursing; however, every rule has its exceptions, so answer with care. Pg. 487

Which patient needs medical attention? Vital signs-----------pt A-------pt B-------pt C-------pt D Carbon dioxide------35--------48---------44---------37 concen. in exhaled air (mm Hg) Temp----------------97.8F------98F-------98.4F-------99F

A. Patient A *B. Patient B* C. Patient C D. Patient D Rationale: A capnograph is a device that records the concentration of carbon dioxide in exhaled air. The normal range of a capnograph reading is 35 to 45 mm Hg. Therefore, patient B, with a carbon dioxide concentration of 48 mm Hg, needs medical attention. The measurements for patients A, C, and D are normal. Pg. 487

Which patient's temperature would be considered harmful? Patient--------------pt A-------pt B-------pt C-------pt D Temperature (F)-----101--------103--------101---------103 Age in years---------6----------10---------45---------50

A. Patient A B. Patient B C. Patient C *D. Patient D* Rationale: A fever is usually not harmful if the temperature is below 102.2° F in adults. So, a temperature of 103° F for patient D would be considered harmful. In children, temperature below 104° F is usually not harmful. Therefore, patients A and B with temperatures of 101° F and 103° F, respectively, are not considered to be at risk. Patient C with a temperature 101° F is also not at risk. Pg. 511

A nurse is monitoring the blood pressure of four older adult patients in the outpatient ward. Which patient does the nurse anticipate to have decreased vessel elasticity? Patient-------Systolic Pressure-------Diastolic Pressure A--------------------80-----------------------60 B--------------------100-----------------------70 C--------------------120-----------------------80 D--------------------140-----------------------90

A. Patient A B. Patient B C. Patient C *D. Patient D* Rationale: Pulse pressure is the difference between the systolic and diastolic blood pressure readings. In older adults, when the systolic pressure is increased, but the diastolic blood pressure is constant, it will result in widened pulse pressure, indicating decreased vessel elasticity. The patient with a pulse pressure of 50 mm Hg has an abnormal parameter. The patient with pulse pressure of 20 mm Hg has a normal parameter. The patient with the pulse pressure of 30 mm Hg has a normal parameter. The patient with pulse pressure of 40 mm Hg has a normal parameter. Pg. 511

The nurse is caring for four patients with different respiratory disorders. Which patient requires immediate nursing intervention? Patient----------Conditions-----------Rate of Respiration A-----------------Asthma----------------12 breaths/min B----------------Bronchitis--------------15 breaths/min C---------------Emphysema------------20 breaths/min D-----------------COPD----------------10 breaths/min

A. Patient A B. Patient B C. Patient C *D. Patient D* Rationale: The patient with chronic obstructive pulmonary disease and a respiratory rate of 10 breaths per minute requires immediate nursing intervention, because the condition is critical. The patient with asthma and a respiratory rate of 12 breaths per minute is in the normal range (12 to 20 breaths per minute). Therefore, this patient would not require immediate nursing intervention. The patient with bronchitis and a respiratory rate of 15 breaths per minute is within the normal range; therefore, this patient would not require immediate nursing interventions. A patient with emphysema and a respiratory rate of 20 breaths per minute is within the normal range. Therefore, this patient would not require immediate nursing intervention. Pg. 487

The nurse is assessing the vital sign reports of four different patients. Which patient reports indicate abnormal vital signs? Vital Signs-----------pt A-------pt B-------pt C------pt D Pulse (beats/min)----75---------70---------60--------55 Temperature (F)-----96.8-------98.9-------100.3------101.1 B/P (mm Hg)-------118/78-----116/76----120/82----132/89 SpO2 (%)-------------95---------96--------96--------92

A. Patient A B. Patient B C. Patient C *D. Patient D* Rationale:The acceptable ranges of vital signs are; pulse 60 to 100 beats/minute, temperature 96.8 to 100.4° F, systolic blood pressure less than 120 mm Hg, diastolic blood pressure less than 80 mm Hg, and pulse oximetry (SpO 2) greater than or equal to 95%. The vital signs of patient D with pulse 55 beats/minute, temperature 101.1° F, blood pressure 132/89 mm Hg, and pulse oximetry of 92% are not in the range of normal values, so the patient requires immediate nursing intervention. The vital signs of the other patients are within normal range. Test-Taking Tip: Chart/exhibit items present a situation and ask a question. A variety of objective and subjective information is presented about the patient in formats such as the medical record (e.g., laboratory test results, results of diagnostic procedures, progress notes, health care provider orders, medication administration record, health history), physical assessment data, and assistant/patient interactions. After analyzing the information presented, the test taker answers the question. These questions usually reflect the analyzing level of cognitive thinking. Pg. 487

Which statement is true regarding the pulse rate of an older adult?

A. Pedal pulse can easily be palpated in older adults. B. Older adults have increased heart rate at rest. *C. It takes longer for the heart rate to rise in older adults during illness.* D. Heart sounds are sometimes muffled due to decreased air space in the lungs. Rationale: It takes longer for the heart rate to rise in the older adults during illness to meet increased demands during conditions such stress, illness, and excitement. Pedal pulses are often difficult to palpate in older adults. Older adults have decreased heart rate at rest. Heart sounds are sometimes muffled or difficult to hear in older adults because of an increase in air space in the lungs. Pg. 511

Which statement about assessing vital signs in older adults is correct?

A. Pedal pulse is easy to palpate in older adults. B. Older adults are less susceptible to hyperthermia. C. Tidal volume in older adults is increased by kyphosis. *D. Muffled heart sounds in older adults indicate air spaces in lungs.* Rationale: Increased air space in the lungs will cause muffled heart sounds. Pedal pulses are often difficult to palpate in older adults. A decrease in sweat gland reactivity in the older adults may result in hyperthermia and heatstroke. Kyphosis and scoliosis that occur in older adults also restrict chest expansion and decrease tidal volume. Pg. 511

Which statement is true regarding the radiation heat loss mechanism of the body?

A. Peripheral vasodilation minimizes radiant heat loss. *B. Radiation is the transfer of heat from one object to another without direct contact.* C. Radiation increases as the temperature difference between the objects decreases. D. The body absorbs heat through radiation if the environment is warmer than the skin. Rationale: Radiation is a heat loss mechanism of the body. If the environment is warmer compared to the skin, the body absorbs heat through radiation without any direct contact. Peripheral vasodilation increases the blood flow from the internal organs to the skin to increase radiant heat loss. Radiation is the transfer of heat from the surface of one object to the surface of another without direct contact between them. Radiation increases as the temperature difference between the objects increases. Pg. 489

While assessing the condition of a 70-year-old patient, the nurse observes decreased tidal volume. What is the likely reason for this observation?

A. Poor muscle control B. Increased air space in lungs *C. Abnormal curvature of the spine* D. Decreased sweat gland reactivity Rationale: Kyphosis is the abnormal curvature of the spine observed in older adults, which causes restriction of chest expansion and decreased tidal volume. Heart sounds are sometimes muffled or difficult to hear in older adults because of an increase in air space in the lungs. Poor muscle control does not cause decreased tidal volume. Decrease in sweat gland activity in older adults results in a higher threshold for sweating at high temperature and leads to hyperthermia and heatstroke. Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses. Pg. 511

The nurse is assessing a patient's vital signs. After assessment, the nurse immediately reports an unstable vital sign to the health care provider. What finding in the patient alerts the nurse to a deviation from the normal range?

A. Pulse pressure of 50 mm Hg B. Rectal temperature of 99.5° F (37.5° C) C. Pulse rate of 62 beats per minute *D. Respiratory rate of 11 breaths per minute* Rationale: The normal acceptable range of respiratory rate is between 12 and 20 breaths per minute; hence, the patient has a reduced respiratory rate (bradypnea). The normal range of pulse pressure is between 30 and 50 mm Hg. The average rectal temperature is 99.5° F (37.5° C). The pulse rate of a normal patient should be in the range of 60 to 100 beats per minute. Pg. 501

Which vital parameter may be altered due to decreased vessel elasticity?

A. Pulse rate *B. Blood pressure* C. Respiratory rate D. Body temperature Rationale: Decreased vessel elasticity will alter the systolic blood pressure. Pulse rate, respiratory rate, and body temperature are not altered by decreased vessel elasticity. Pg. 511

A patient is admitted for dehydration caused by pneumonia and shortness of breath. He has a history of heart disease and cardiac dysrhythmias. The nursing assistant tells you his admitting vital signs. Which measurement should you reassess? Select all that apply.

A. Right arm blood pressure: 120/80 *B. Radial pulse rate: 72 and irregular* C. Temporal temperature: 37.4° C (99.3° F) *D. Respiratory rate: 28* *E. Oxygen saturation: 99%* Rationale: An irregular pulse may be the result of a complication of heart disease and requires the assessment of the apical rate. A respiratory rate of 28 is abnormal, yet the oxygen saturation is normal. Both oxygen saturation and respiratory rate would be expected to be outside of the acceptable range. The patient's blood pressure is within normal limits, and the temperature is within the normal adult range. Pg. 487, 497

What is a reason for over-sensitivity of older adults to the environmental temperature?

A. Scoliosis B. Poor muscle control C. Decreased sweat gland reactivity *D. Inefficient thermo-regulatory system* Rationale: Older adults are very sensitive to slight changes in environmental temperature due to the inefficiency of their thermo-regulatory systems. Scoliosis that occurs in the older patients may restrict chest expansion and decrease tidal volume; it does not affect sensitivity to environmental temperature. Poor muscle control may decrease the ability of older patients to close their mouths leading to an inaccurate reading of oral temperature. Decreased sweat gland reactivity of the older patient may cause hyperthermia and heat stroke. Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses. Pg. 511

While assessing the heart sounds of a patient, the nurse notices muffled sounds. What could be the possible reason?

A. The rigidity of rib cage B. The downward slanting of ribs C. The ossification of costal cartilage *D. The increased airspace in the lungs* Rationale: In older adults, sometimes it is difficult to hear the heart sounds. These sounds may appear muffled due to an increase in the air space in the lungs. A patient with a rigid rib cage may have reduced chest wall expansion. The downward slanting of the ribs may decrease the tidal volume. Due to aging, ossification of costal cartilage may occur. This would cause a reduction in chest wall expansion. Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses. Pg. 511

The nurse is caring for a patient who underwent a hysterectomy. In which situation should the nurse measure the vital signs? Select all that apply.

A. When the patient eats *B. During the infusion of blood products* C. When the patient has decreased pain intensity *D. When the patient reports that she feels "different"* *E. Before the patient performs range-of-motion exercises* Rationale: The nurse should measure the vital signs before, during, and after the transfusion of blood products. The vital signs should be measured when the patient reports nonspecific symptoms of physical distress, such as feeling "funny" or "different." The nurse should measure vital signs in case of conditions that may influence vital signs, such as before performing range-of-motion (ROM) exercises, because the vital signs may vary while performing ROM exercises. The nurse would not measure vital signs when the patient is eating because eating would not have any influence on vital signs. The nurse should measure vital signs when the patient has increased intensity of pain, not decreased intensity. Pg. 487