Chapter 8: Assessing General Status and Vital Signs

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 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 patient and obtained a reading of 128/78 mm Hg. What is this patient's pulse pressure?

50 mm Hg Systolic-diastolic 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 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?

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 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 The major defining characteristics of anxiety are present: loss of sleep, feeling unsafe, inability to concentrate, and poor eye contact.

Which abnormal skin color should a nurse anticipate assessing on a dark-skinned client?

Ashen gray

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 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 Assess the patient's skin tone and the presence or absence of sweating to determine whether the patient is febrile Use a disposable mercury thermometer to take the patient's temperature Take the patient's temperature rectally

Assess the patient's temperature by axilla The axillary site is an accurate and acceptable alternative when other sites are impractical or contraindicated. Rectal temperatures are contraindicated in cardiac patients; mercury thermometers are not commonly used. It is unacceptable for the nurse to rely solely on subjective assessments to determine whether the patient is febrile.

After assessing a patient'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.

The nursing instructor is discussing the function of sebaceous glands in the body. What would the teacher explain as the purpose of sebum to the students?

Assists in friction protection & assists the skin with moisture retention

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

Cushing's syndrome

The nurse should immediately notify the healthcare provider if which assessment finding is obtained on a hospitalized client?

Cyanotic left lower extremity

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 On the other hand; Objective findings, which are obtained by the nurses direct observation or assessment, include respiratory rate, core body temperature, and blood pressure.

The nurse is preparing to perform a physical examination of a client who is an Orthodox Jew. Which of the following accommodations should the nurse be prepared to make for this client, based on his religious beliefs?

Have a nurse who is the same sex as the client examine him Clients from conservative religious groups (e.g., Orthodox Jews or Muslims) may require that the nurse be the same sex as the client. The client must still undress and put on an examination gown. It is not likely that the client will want to pray before the examination, and it is not necessary to avoid asking questions regarding his lifestyle.

The nurse explains to the client that smoking has what effect on the body? Select all that apply.

Hypertension Vasoconstriction Peripheral vascular disease

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 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.

Prior to inflating the cuff to measure the client's blood pressure, the nurse has palpated the radial artery, inflated the cuff, and noted the point at which the radial pulse disappears. What is the rationale for the nurse's action?

It prevents client discomfort and an auscultatory gap. Estimating systolic pressure by palpation allows the nurse to gauge how high to inflate the cuff, thus preventing overinflation and consequent discomfort, as well as avoiding errors related to an auscultatory gap.

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's syndrome

A patient recovering from a stroke complains of pain. The nurse suspects this patient is most likely experiencing which type of pain? Nociceptive Neuropathic Somatic Idiopathic

Neuropathic Neuropathic pain can occur from central nervous system brain injury caused by a stroke. Nociceptive pain is caused by tissue damage. Somatic pain is another term used for nociceptive pain. Idiopathic pain does not have an identified cause.

A nurse is caring for a patient who is ambulating for the first time after surgery. Upon standing, the patient complains of dizziness and faintness. The patient's blood pressure is 90/50. What is the name for this condition?

Orthostatic hypotension 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.

The nurse places the following device on a client's finger. What information is this device providing to the nurse?

Oxygen saturation 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.

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

Palpating the flow of blood through an artery

Parents bring a child to the clinic and report a "rash" on her knee. On assessment, the nurse practitioner notes the area to be a reddish-pink lesion covered with silvery scales. What would the nurse practitioner chart?

Psoriasis

An approximate reading of core body temperature can be taken at various anatomic sites. Which of the following would not be a correct place to take a core body temperature? Under the tongue. Forehead and temporal artery. Opening of ear. Rectum. Groin.

Rectum. For the body to function on a cellular level, a core body temperature between 36.5°C and 37.7°C (96.0°F and 99.9°F orally) must be maintained.

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

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 The older clients artery may feel more rigid, hard, and bent. More rigid, arteriosclerotic arteries account for higher systolic blood pressure in older adults.

You are educating your patient on taking blood pressure at home. What would be important to include in your patient education?

Routine recalibration of the device Follow the guidelines listed, and advise your patients about how to choose the best cuff for home use. Urge them to have their home devices recalibrated routinely.

Various sounds are heard when assessing a blood pressure. What does the first sound heard through the stethoscope represent?

Systolic pressure

A nurse is assessing the blood pressure of a team of healthy athletes at the heath care facility. Which of the following observations can be made by the nurse and athletes by measuring the blood pressure?

The ability of the arteries to stretch Measuring the blood pressure helps to assess the efficiency of the client's circulatory system. Blood pressure measurements reflect the ability of the arteries to stretch, the volume of circulating blood, and the amount of resistance the heart must overcome when it pumps blood.

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. 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 client arrives at the emergency department by ambulance after an accident while playing softball. The client's left leg is swollen and deformed. The client describes the pain as a 9 on a 10-point scale. When the nurse assesses the client's blood pressure, what would the nurse expect to find?

The blood pressure is elevated Many variables affect vital signs, including pain, stress, anxiety, and activity. Pain and anxiety can contribute to increased blood pressure. The nurse would not expect to find the blood pressure lower than normal or within normal limits with the client's report of pain as a 9 on a 10-point scale.

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?

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.

client comes to the cardiovascular intensive care unit (CVICU) directly after a three-vessel coronary artery bypass graft (CABG). The client's orders state "maintain systolic blood pressure >90 but <120." How does this order affect the monitoring of the client's blood pressure?

The nurse will assess blood pressure more frequently to ensure that it does not go beyond the ordered limits Vital signs reflect health status, cardiopulmonary function, and overall body function. They are called vital signs because of their importance as indicators of physiological state and response to physical, environmental, and psychological stressors. Changes in vital signs often indicate changes in health. 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. It would not be appropriate to monitor this client's BP every hour or every 4 hours or to delegate the taking of this client's BP to a patient care assistant.

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 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.

The nurse begins a client assessment by conducting a general survey that focuses on objective observations. What is the primary purpose for collecting this sort of information first? assists the nurse in formulating appropriate subjective questioning allows the nurse to form an effective nurse-client relationship permits the nurse to initiate the assessment in a nonthreatening manner demonstrates the nurse's therapeutic interest in the client

assists the nurse in formulating appropriate subjective questioning The General Survey chapter provides an overview of the nurse's initial client assessment prior to exploring each system in detail. The objective observation of the client begins with the first moments of the encounter and continues throughout the history and physical examination. The nonverbal cues collected during the general survey enable the nurse to select appropriate subjective questions for the individual client to garner more information. While the remaining options are true statements concerning a general survey, none demonstrate the primary purpose for the collection of objective information.

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

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. 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.

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

oral: 37.0°C The normal range for an oral temperature is 37.0°C, a rectal temperature is 37.5°C, an axillary temperature is 36.5°C, and a tympanic temperature is 37.5°C.

The current blood pressure measurement on a 24-hour uncomplicated postoperative patient 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

The nurse is having difficulty auscultating Korotkoff sounds. The nurse should (Select all that apply.)

reposition the stethoscope consider shock be certain there is full skin contact with the bell

While assessing an older adult client's respirations, the nurse can anticipate that the respiratory pattern may exhibit a

shorter inspiratory phase. In the older adult, the respiratory rate may range from 15 to 22. The rate may increase with a shallower inspiratory phase because vital capacity and inspiratory reserve volume decrease with aging.

The nurse assesses an older adult bedridden client in her home. While assessing the client's buttocks, the nurse observes that a small area of the skin is broken and resembles an erosion. The nurse should document the client's pressure ulcer as

stage II.

Short, pale, and fine hair that is present over much of the body is termed

vellus.