Lab 3: Vital Signs, and Nursing Assessment.

Malignant hyperthermia

A hereditary condition of uncontrolled heat production that occurs when susceptible people receive certain anesthetic drugs.

1. A patient has a head injury and damages the hypothalamus. Which vital sign will the nurse monitor most closely? a. Pulse b. Respirations c. Temperature d. Blood pressure

ANS: C Disease or trauma to the hypothalamus or the spinal cord, which carries hypothalamic messages, causes serious alterations in temperature control. The hypothalamus does not control pulse, respirations, or blood pressure.

dysrhythmia

Abnormal heart rhythm

Hyperthermia

Abnormally high body temperature

blood pressure

Pressure exerted by the blood upon the walls of the blood vessels, especially arteries, usually measured by means of a sphygmomanometer and expressed in millimeters of mercury.

Convection

Process by which, in a fluid being heated, the warmer part of the mass will rise and the cooler portions will sink.

systolic pressure

The blood pressure generated by the heart during contraction.

conduction

The direct transfer of heat from one substance to another substance that it is touching.

perfusion

The supply of oxygen to and removal of wastes from the cells and tissues of the body as a result of the flow of blood through the capillaries.

core temperature

The temperature of the central part of the body (eg, the heart, lungs, and vital organs).

oxygen saturation

a clinical measurement of the percentage of hemoglobin that is bound with oxygen in the blood

Normal respiration rate

12-20 breaths per minute

Normal pulse for adults

60-100 bpm

normal pulse for children

80-120 bpm

Normal temperature range

96.8-100.4

4. A nurse is conducting Weber's test. Which action will the nurse take? a. Place a vibrating tuning fork in the middle of patient's forehead. b. Place a vibrating tuning fork on the patient's mastoid process. c. Compare the number of seconds heard by bone versus air conduction. d. Compare the patient's degree of joint movement to the normal level.

ANS: A During Weber's test (lateralization of sound), the nurse places the vibrating tuning fork in the middle of the patient's forehead. During a Rinne test (comparison of air and bone conduction), the nurse places a vibrating tuning fork on the patient's mastoid process and compares the length of time air and bone conduction is heard. Comparing the patient's degree of joint movement to the normal level is a test for range of motion.

1. The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase? a. Completes a comprehensive database b. Identifies pertinent nursing diagnoses c. Intervenes based on priorities of patient care d. Determines whether outcomes have been achieved

ANS: A The assessment phase of the nursing process involves data collection to complete a thorough patient database and is the first phase. Identifying nursing diagnoses occurs during the diagnosis phase or second phase. The nurse carries out interventions during the implementation phase (fourth phase), and determining whether outcomes have been achieved takes place during the evaluation phase (fifth phase) of the nursing process.

8. While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. What should the nurse do? a. Consider cultural differences during this assessment. b. Ask the patient to make eye contact to determine her affect. c. Continue with the interview and document that the patient is depressed. d. Notify the health care provider to recommend a psychological evaluation.

ANS: A To conduct an accurate and complete assessment, consider a patient's cultural background. This nurse needs to practice culturally competent care and appreciate the cultural differences. Assuming that the patient is depressed or in need of a psychological evaluation or to force eye contact is inappropriate.

6. The nurse is caring for a patient who has a temperature reading of 100.4° F (38° C). The patient's last two temperature readings were 98.6° F (37° C) and 96.8° F (36° C). Which action will the nurse take? a. Wait 30 minutes and recheck the patient's temperature. b. Assume that the patient has an infection and order blood cultures. c. Encourage the patient to move around to increase muscular activity. d. Be aware that temperatures this high are harmful and affect patient safety. .

ANS: A Waiting 30 minutes and rechecking the patient's temperature would be the most appropriate action in this case. A fever is usually not harmful if it stays below 102.2° F (39° C), and a single temperature reading does not always indicate a fever. In addition to physical signs and symptoms of infection, a fever determination is based on several temperature readings at different times of the day compared with the usual value for that person at that time. Nurses should base actions on knowledge, not on assumptions. Encouraging the patient to increase muscular activity will cause heat production to increase up to 50 times normal. The temperature has decreased and a symptom of infection would be an increase in temperature

2. A nurse is using the problem-oriented approach to data collection. Which action will the nurse take first? a. Complete the questions in chronological order. b. Focus on the patient's presenting situation. c. Make accurate interpretations of the data. d. Conduct an observational overview.

ANS: B A problem-oriented approach focuses on the patient's current problem or presenting situation rather than on an observational overview. The database is not always completed using a chronological approach if focusing on the current problem. Making interpretations of the data is not data collection. Data interpretation occurs while appropriate nursing diagnoses are assigned. The question is asking about data collection

9. A nurse has already set the agenda during a patient-centered interview. What will the nurse do next? a. Begin with introductions. b. Ask about the chief concerns or problems. c. Explain that the interview will be over in a few minutes. d. Tell the patient "I will be back to administer medications in 1 hour."

ANS: B After setting the agenda, the nurse should conduct the actual interview and proceed with data collection, such as asking about the patient's current chief concerns or problems. Introductions occur before setting the agenda. Begin an interview by introducing yourself and your position and explaining the purpose of the interview. Your aim is to set an agenda for how you will gather information about a patient's current chief concerns or problems. The termination phase includes telling the patient when the interview is nearing an end. Telling the patient that medications will be given later when the nurse returns would typically take place during the termination phase of the interview.

3. The patient has a temperature of 105.2° F. The nurse is attempting to lower temperature by providing tepid sponge baths and placing cool compresses in strategic body locations. Which technique is the nurse using to lower the patient's temperature? a. Radiation b. Conduction c. Convection d. Evaporation

ANS: B Applying an ice pack or bathing a patient with a cool cloth increases conductive heat loss because of the direct contact. Radiation is the transfer of heat from the surface of one object to the surface of another without direct contact between the two. Evaporation is the transfer of heat energy when a liquid is changed to a gas. Convection is the transfer of heat away from the body by air movement.

1. A nurse is a preceptor for a nurse who just graduated from nursing school. When caring for a patient, the new graduate nurse begins to explain to the patient the purpose of completing a physical assessment. Which statement made by the new graduate nurse requires the preceptor to intervene? a. "I will use the information from my assessment to figure out if your antihypertensive medication is working effectively." b. "Nursing assessment data are used only to provide information about the effectiveness of your medical care." c. "Nurses use data from their patient's physical assessment to determine a patient's educational needs." d. "Information gained from physical assessment helps nurses better understand their patients' emotional needs."

ANS: B Nursing assessment data are used to evaluate the effectiveness of all aspects of a patient's care, not just the patient's medical care. Assessment data help to evaluate the effectiveness of medications and to determine a patient's health care needs, including the need for patient education. Nurses also use assessment data to identify patients' psychosocial and cultural needs.

11. A nurse is conducting a nursing health history. Which component will the nurse address? a. Nurse's concerns b. Patient expectations c. Current treatment orders d. Nurse's goals for the patient

ANS: B Some components of a nursing health history include chief concern, patient expectations, spiritual health, and review of systems. Current treatment orders are located under the Orderssection in the patient's chart and are not a part of the nursing health history. Patient concerns, not nurse's concerns, are included in the database. Goals that are mutually established, not nurse's goals, are part of the nursing care plan.

10. The nurse is attempting to prompt the patient to elaborate on the reports of daytime fatigue. Which question should the nurse ask? a. "Is there anything that you are stressed about right now that I should know?" b. "What reasons do you think are contributing to your fatigue?" c. "What are your normal work hours?" d. "Are you sleeping 8 hours a night?"

ANS: B The question asking the patient what factors might be contributing to the fatigue will elicit the best open-ended response. Asking whether the patient is stressed and asking if the patient is sleeping 8 hours a night are closed-ended questions eliciting simple yes or no responses. Asking about normal work hours will elicit a matter-of-fact response and does not prompt the patient to elaborate on the daytime fatigue or ask about the contributing reasons

2. A patient presents with heatstroke. The nurse uses cool packs, cooling blanket, and a fan. Which technique is the nurse using when the fan produces heat loss? a. Radiation b. Conduction c. Convection d. Evaporation

ANS: C Convection is the transfer of heat away from the body by air movement. Conduction is the transfer of heat from one object to another with direct contact. Radiation is the transfer of heat from the surface of one object to the surface of another without direct contact between the two. Evaporation is the transfer of heat energy when a liquid is changed to a gas.

4. The nurse is gathering data on a patient. Which data will the nurse report as objective data? a. States "doesn't feel good" b. Reports a headache c. Respirations 16 d. Nauseated

ANS: C Objective data are observations or measurements of a patient's health status, like respirations. Inspecting the condition of a surgical incision or wound, describing an observed behavior, and measuring blood pressure are examples of objective data. States "doesn't feel good," reports a headache, and nausea are all subjective data. Subjective data include the patient's feelings, perceptions, and reported symptoms. Only patients provide subjective data relevant to their health condition.

5. A patient expresses fear of going home and being alone. Vital signs are stable and the incision is nearly completely healed. What can the nurse infer from the subjective data? a. The patient can now perform the dressing changes without help. b. The patient can begin retaking all of the previous medications. c. The patient is apprehensive about discharge. d. The patient's surgery was not successful.

ANS: C Subjective data include expressions of fear of going home and being alone. These data indicate (use inference) that the patient is apprehensive about discharge. Expressing fear is not an appropriate sign that a patient is able to perform dressing changes independently. An order from a health care provider is required before a patient is taught to resume previous medications. The nurse cannot infer that surgery was not successful if the incision is nearly completely healed.

3. After reviewing the database, the nurse discovers that the patient's vital signs have not been recorded by the nursing assistive personnel (NAP). Which clinical decision should the nurse make? a. Administer scheduled medications assuming that the NAP would have reported abnormal vital signs. b. Have the patient transported to the radiology department for a scheduled x-ray, and review vital signs upon return. c. Ask the NAP to record the patient's vital signs before administering medications. d. Omit the vital signs because the patient is presently in no distress.

ANS: C The nurse should ask the nursing assistive personnel to record the vital signs for review before administering medicines or transporting the patient to another department. The nurse should not make assumptions when providing high-quality patient care, and omitting the vital signs is not an appropriate action.

7. A nurse is gathering information about a patient's habits and lifestyle patterns. Which method of data collection will the nurse use that will best obtain this information? a. Carefully review lab results. b. Conduct the physical assessment. c. Perform a thorough nursing health history. d. Prolong the termination phase of the interview.

ANS: C The nursing health history also includes a description of a patient's habits and lifestyle patterns. Lab results and physical assessment will not reveal as much about the patient's habits and lifestyle patterns as the nursing health history. Collecting data is part of the working phase of the interview.

14. Which statement by a nurse indicates a good understanding about the differences between data validation and data interpretation? a. "Data interpretation occurs before data validation." b. "Validation involves looking for patterns in professional standards." c. "Validation involves comparing data with other sources for accuracy." d. "Data interpretation involves discovering patterns in professional standards."

ANS: C Validation, by definition, involves comparing data with other sources for accuracy. Data interpretation involves identifying abnormal findings, clarifying information, and identifying patient problems. The nurse should validate data before interpreting the data and making inferences. The nurse is interpreting and validating patient data, not professional standards.

6. Which method of data collection will the nurse use to establish a patient's database? a. Reviewing the current literature to determine evidence-based nursing actions b. Checking orders for diagnostic and laboratory tests c. Performing a physical examination d. Ordering medications

ANS: C You will learn to conduct different types of assessments: the patient-centered interview during a nursing health history, a physical examination, and the periodic assessments you make during rounding or administering care. A nursing database includes a physical examination. The nurse reviews the current literature in the implementation phase of the nursing process to determine evidence-based actions, and the health care provider is responsible for ordering medications. The nurse uses results from the diagnostic and laboratory tests to establish a patient database, not checking orders for tests.

1. A nurse is completing an assessment. Which findings will the nurse report as subjective data? (Select all that apply.) a. Patient's temperature b. Patient's wound appearance c. Patient describing excitement about discharge d. Patient pacing the floor while awaiting test results e. Patient's expression of fear regarding upcoming surgery .

ANS: C, E Subjective data include patient's feelings, perceptions, and reported symptoms. Expressing feelings such as excitement or fear is an example of subjective data. Objective data are observations or measurements of a patient's health status. In this question, the appearance of the wound and the patient's temperature are objective data. Pacing is an observable patient behavior and is also considered objective data

13. The nurse begins a shift assessment by examining a surgical dressing that is saturated with serosanguineous drainage on a patient who had open abdominal surgery yesterday (or 1 day ago). Which type of assessment approach is the nurse using? a. Gordon's Functional Health Patterns b. Activity-exercise pattern assessment c. General to specific assessment d. Problem-oriented assessment

ANS: D The nurse is not doing a complete, general assessment and then focusing on specific problem areas. Instead, the nurse focuses immediately on the problem at hand (dressing and drainage from surgery) and performs a problem-oriented assessment. Utilizing Gordon's Functional Health Patterns is an example of a structured database-type assessment technique that includes 11 patterns to assess. The nurse in this question is performing a specific problem-oriented assessment approach, not a general approach. The nurse is not performing an activity-exercise pattern assessment in this question.

12. While the patient's lower extremity, which is in a cast, is assessed, the patient tells the nurse about an inability to rest at night. The nurse disregards this information, thinking that no correlation has been noted between having a leg cast and developing restless sleep. Which action would have been best for the nurse to take? a. Tell the patient to just focus on the leg and cast right now. b. Document the sleep patterns and information in the patient's chart. c. Explain that a more thorough assessment will be needed next shift. d. Ask the patient about usual sleep patterns and the onset of having difficulty resting.

ANS: D The nurse must use critical thinking skills in this situation to assess first in this situation. The best response is to gather more assessment data by asking the patient about usual sleep patterns and the onset of having difficulty resting. The nurse should assess before documenting and should not ignore the patient's report of a problem or postpone it till the next shift.

Tachycardia

Abnormally rapid heartbeat

frostbite

Actual freezing of tissue fluid resulting in damage to the skin and underlying tissue

pyrogens

Bacteria and viruses that elevate body temperature

orthostatic hypotension

Decrease in blood pressure related to positional or postural changes from lying to sitting or standing positions

assess

Gather information about the patient's condition

antipyretic

Medication used to reduce a fever

nonshivering thermogenesis

Occurs primarily in neonates. Because neonates cannot shiver, a limited amount of vascular brown adipose tissue present at birth can be metabolized for heat production.

Stage 2 hypertension

Systolic- >160 Diastolic- >100

prehypertension range

Systolic: 120-139 Diastolic: 80-89

Stage 1 hypertension

Systolic: 140-159 Diastolic: 90-99

heat stroke

a condition caused by too long an exposure to high temperatures, causing high fever, headaches, hot, dry skin, physical exhaustion and sometimes physical collapse and coma.

capnography

a method to monitor ventilation and, indirectly, blood flow through the lungs

hypothermia

abnormally low body temperature

Bradycardia

abnormally slow heartbeat

pyrexia

another term for fever

heat exhaustion

condition resulting from exposure to heat and excessive loss of fluid through sweating

hypoxemia

deficient amount of oxygen in the blood

evauate

determine if goals and outcomes were achieved

pulse deficit

difference between the apical and radial pulse rates

diaphoresis

excessive sweating

febrile

feverish

normal blood pressure

less than 120/80

afebrile

no fever

eupnea

normal breathing

diastolic pressure

occurs when the ventricles are relaxed; the lowest pressure against the walls of an artery

hematocrit

percentage of blood volume occupied by red blood cells

implement

putting nursing plan in to action

plan

set goals of care and desired outcomes and identify appropriate nursing actions

postural hypotension

sudden drop in blood pressure upon standing

auscultatory gap

temporary disappearance of sounds usually heard over the brachial artery, occurring when the cuff pressure is high and is gradually reduced, with the sounds again heard at a lower level of pressure (usually occurring in patients who have hypertension)

pulse pressure

the difference between systolic and diastolic blood pressure

Thermoregulation

the maintenance of body temperature within a range that enables cells to function efficiently.

diffusion

the process by which molecules move from an area of higher concentration to an area of lower concentration

diagnose

to identify a disease through symptoms