ATI: Vital Signs

Pulse Force or Strength

0 = absent +1 = weak/thready +2 = normal/expected +3/+4 = full/bounding

Wash hands with antimicrobial soap for

15-30 seconds

Diurnal cycle

24 hour cycle

Auscultatory Gap

A silent interval that may be present between the systolic and diastolic blood pressures; i.e., the sound disappears for a while, then reappears

A 56-year-old female had her initial visit with a primary care provider (PCP) 2½ months ago. At that appointment, her blood-pressure (BP) was elevated. Her BP was reassessed in 2 weeks and remained above normal limits for an adult her age. The PCP prescribed an antihypertensive medication and encouraged her to implement several lifestyle changes directed at lowering her BP. She made a 2-month follow-up appointment for re-evaluation of her response to the treatment plan. The patient has been taking the prescribed antihypertensive medication for 2 months. You prepare to assess her BP. After you interview her to determine when she last smoked, ingested caffeine, and exercised, you make sure she is seated comfortably with her arm supported at the level of her heart. You position a standard adult blood-pressure cuff snugly on her bare arm about 1 inch above the anticubital space. To ensure an accurate reading with the aneroid sphygmomanometer you are using, you position yourself A. within 3 feet of the manometer. B. at eye level with the BP gauge. C. standing at the patient's side. D. however you feel most comfortable.

A, B

When listening to Korotkoff sounds, you would use your stethoscope's A. bell. B. diaphragm.

A, B

The reason for removing the outer sweater is to A. ensure proper cuff application. B. prevent falsely high readings. C. make the patient more comfortable. D. allow for proper inflation of the cuff's bladder. E. eliminate any muffling of the Korotkoff sounds.

A, B, D, E

Positioning and supporting the patient's arm at heart level is important because A. an unsupported arm can cause a falsely high reading. B. an arm positioned below heart level can cause a falsely high reading. C. an arm positioned above heart level can cause a falsely low reading. D. it ensures a good blood flow conducive to an accurate reading.

A, C

You have reviewed the patient's records to determine her baseline BP, but if that had not been possible it would be appropriate for you to A. measure her BP on one arm, remove the cuff, wait at least 2 minutes, measure it on the other arm, and average the two values. B. measure her BP, reinflate the cuff promptly, measure it again, and average the two values. C. inflate the cuff to 30 mm Hg above the point of the previously palpated systolic pressure. D. ask the patient what her BP usually is and inflate the cuff to 30 mm Hg above that point.

A, C

Your patient's blood pressure exceeds the upper limit of the normal range for an adult, so you measure it again. Which of the following questions would be appropriate to ask your patient before you reassess her blood pressure? A. What is your usual blood-pressure reading? B. Have you eaten anything within the last hour? C. Did you drink any tea, coffee, or soda within the last half hour? D. Are you currently experiencing any emotional stress such as fear or anxiety? E. Have you smoked within the last 15 to 30 minutes?

A, C, D, E

When preparing to measure the vital signs of a patient, you should recognize that which of the following will affect the methods that you will use? A. The patient is 60 pounds overweight. B. The patient has been nauseated for 2 days. C. The patient is reporting a "stuffy" nose. D. The patient has been fasting for blood tests. E. The patient is taking digoxin (Lanoxin). F. The patient had a mastectomy 2 years ago.

A, C, D, E, F

You inflate the cuff to 30 mm Hg higher than the patient's last recorded BP (taken at her last appointment). You note the point on the manometer where A. you first hear Korotkoff sounds. B. the swishing sounds begin. C. you hear the loudest sounds. D. the sound becomes muffled. E. the sound disappears.

A, E

You are assessing a patient's vital signs. The patient has a temperature of 102F (39C). Which of the following do you expect to find? A. An elevated pulse rate B. A decreased blood pressure C. An elevated blood pressure D. A decreased pulse rate

A. A fever increases metabolic rate and peripheral vasodilation, resulting in an increased pulse rate.

When using a tympanic membrane thermometer, correctly position the speculum probe with respect to the ear canal to ensure A. an appropriate seal is created to prevent the ear canal from being exposed to ambient temperature. B. that the risk of transmission of micro-organisms is reduced.

A. Gentle pressure seals the ear canal from ambient temperature, which can alter readings as much as 2.8° C (5° F).

You determine that the patient's arm seems "average" and decide to use a standard blood-pressure cuff. You check that her pulse is of equal strength in both wrists, so, after she removes her outer long-sleeved sweater, you position the lower edge of the BP cuff approximately 1 inch above the antecubital space of her right arm. You support her arm at approximately the level of her heart. Selecting a BP cuff that is too small for the patient's arm will result in A. a falsely high reading. B. a falsely low reading.

A. Ideally, the cuff's width should be 40% of the circumference (or 20% wider than the diameter) of the midpoint of the limb and the bladder should encircle at least 80% of the upper arm. A cuff that is too small will result in a reading that is falsely high reading, while a cuff that is too big will yield a falsely low reading. There is no way to predetermine the amount of the error in the reading.

To facilitate straightening the natural curvature of the adult ear canal, you gently pull the patient's pinna (top of the ear) A. back, up, and out. B. forward, up, and out. C. back, down, and out.

A. Manipulating the ear lobe in this fashion straightens the adult ear canal, thus providing better exposure of the tympanic membrane and allowing for optimal assessment.

Which of the following accurately describes body temperature? A. The difference between heat produced by and lost from the body B. The total amount of heat produced by the body C. The amount of heat produced by the body plus the amount of heat lost to the external environment

A. Normal body temperature is the healthy balance between the amounts of heat the body produces as a byproduct of metabolism, muscle activity, thyroxine output, and sympathetic stimulation and the heat lost as a result of radiation, conduction, convection, and evaporation.

You place the lower edge of the cuff at least 1 inch above the antecubital space to A. allow for proper placement of the stethoscope over the brachial artery. B. facilitate the proper flexing of the patient's arm at the elbow. C. ensure appropriate application of pressure to the brachial artery.

A. Positioning the cuff this way keeps the cuff from interfering with proper placement of the bell over the brachial artery. Proper positioning is essential for hearing the Korotkoff sounds and accurately measuring blood pressure.

To assess the patient's pulse accurately, you compress the radial artery with A. the pads of your fingers. B. the tips of your fingers. C. the pad of your thumb.

A. The finger pads are most sensitive and thus best suited for detecting the pulse, while the thumb pulsates strongly enough for you to mistake it for the patient's pulse.

You are measuring a patient's temperature orally. You place the covered probe A. in the posterior lingual pocket lateral to the midline. B. so that it rests on the lower lingual frenulum. C. centrally on top of the patient's tongue. D. under the tongue just beyond the patient's teeth.

A. The heat produced by superficial blood vessels in the right and the left posterior sublingual pocket is what generates an accurate oral temperature reading. Inserting the probe "sideways" into the back of the area under the tongue on the left or the right will access this area.

The primary reason for assessing this patient's vital signs is to A. establish a baseline when the patient reports no specific health-related problem. B. determine the presence of any acute or chronic illness or disease process. C. initiate the nursing process.

A. Vital signs are assessed for various reasons that include determining the patient's response to medical and nursing therapy as well as identifying clinical problems. However, the primary reason for such assessment at an initial visit of an apparently well patient is to document baseline data. This information will be useful for comparison with vital-sign data obtained at subsequent visits.

How long would you wait before reassessing your patient's blood pressure on the same arm? A. 2 to 3 minutes B. 10 to 15 minutes

A. Waiting 2 to 3 minutes before reassessing blood pressure in the same extremity allows time for the venous congestion caused by the previous blood pressure measurement to subside.

Which of the following is true regarding assessing a patient's pulse? A. The human pulse is the palpable bounding of the blood flow in a peripheral artery. B. The normal pulse range for a resting adult is 50 to 110 beats/min. C. Three components that the nurse should include when documenting pulse (P) are the rate, rhythm, and depth. D. To calculate the pulse of a patient whose rhythm is irregular, the nurse should count the pulse rate for 30 seconds and multiply by two.

A. When a peripheral artery can be compressed against an underlying bone or muscle, the pulsation created by the ejection of blood from the heart can be felt by palpating that site.

After assessing the patient's pulse, you begin to observe her breathing pattern immediately without changing the position of your hand. You do this primarily to A. keep the patient from altering the rate, rhythm, or depth of her respiration. B. use a time-conserving method of evaluating both respiration and pulse rate. C. offer the reassurance of physical touch while evaluating respiration.

A. When patients are aware that their breathing is being observed, they might inadvertently or knowingly alter respiratory depth, rhythm, or rate.

The best way to determine the depth of a patients respiration is to A. observe the degree of chest-wall movement during inspiration and expiration. B. count how many breathing cycles you observe per minute. C. notice whether or not expiration takes longer than inspiration. D. measure the precise amount of air the patient takes in and breathes out.

A. You determine the depth of respiration subjectively by evaluating how much chest-wall movement you can observe. The movement is generated by the movements of the diaphragm and intercostal muscles as the patient breathes. With shallow respiration, for example, you will observe very little movement. Deep respiration involves full expansion of the lungs, which is usually quite visible.

Factors that affect pulse

Age, gender, circadian rhythm, blood volume, body temperature, exercise, stress, emotion, hormonal activity, medications, pathological processes

Influences on blood pressure

Age, sex, race, diurnal rhythm, weight, exercise, emotions, stress, position

Pulse Elasticity

Artery feels springy instead of tough, hard, rope-like

Your patient is seated comfortably. You measure her blood pressure in her right arm and obtain a reading of 160/90. You ask her to return to have her blood pressure reassessed in 2 weeks since this reading indicates a blood pressure above the normal adult range. The most appropriate way for you to document this patient's blood pressure is A. blood pressure is 160/90 B. BP = 160/90; right arm, sitting C. BP = hypertensive at 160/90

B. Appropriate documentation of blood pressure includes the abbreviation for blood pressure (BP), the systolic pressure separated from the diastolic pressure by a slash mark, plus the assessed limb and general position of the patient.

Which of the following is true regarding assessing a patient's respiration? A. It is best to inform the patient that you are assessing her respiration. B. "R = 14/min, normal, regular" is an appropriate documentation of a patient's respiration. C. Occurrence or periods of apnea in an older adult is a normal respiratory finding. D. Anxiety and acute pain are two factors that should not affect a patient's respiratory rate.

B. Appropriate documentation of respiration includes rate, rhythm (regular, irregular), and depth (deep, normal, shallow).

Which of the following temperatures is within the normal range for adults and is documented correctly? A. T = 98.6º F B. T = 99.6º F (O) C. T = 101.0º F (O)

B. Normal temperatures range from 96.8° F to 100.4° F. Appropriate documentation of temperature (T) includes degrees, scale (F), and assessment site: oral (O), tympanic (T), axillary (A), or rectal (R).

Will your assessment of respiration provide information about your patient's ability to intake carbon dioxide and to expel oxygen? A. Yes B. No

B. Respiration is the mechanism a person uses to introduce oxygen into the body while expelling carbon dioxide into the atmosphere.

Which of the following describes systolic pressure? A. The force blood exerts on the wall of a blood vessel during both the contraction and relaxation phases of the heart B. The pressure exerted by the blood during the heart's contraction phase C. The pressure exerted by the blood during the heart's relaxation phase

B. Systolic pressure describes the pressure exerted by the blood during the hearts contraction phase. The contraction of the heart forces the blood under high pressure into the aorta. The peak of maximum pressure when ejection occurs is the systolic pressure.

The difference between a patient's systolic and diastolic blood pressure is called A. an auscultatory gap. B. the pulse pressure. C. a diurnal variation. D. the pulse deficit.

B. The difference between the systolic and diastolic pressures is the pulse pressure; if the patient's blood pressure is 130/85 mm Hg, the pulse pressure is 45/min. Pulse pressure can be a predictor of heart problems, especially in older adults. For example, an elevated pulse pressure usually reflects stiffness and reduced elasticity of the aorta, most often due to hypertension or atherosclerosis.

When assessing a patient's respiration, it is recommended that the patient A. lie flat in bed with his/her head on a pillow. B. have the head of the bed elevated 45 to 60°. C. continue to go about his/her usual activities. D. take several deep breaths prior to the assessment.

B. This is a comfortable position for most patients and it allows full ventilatory movement. Also, any type of discomfort can increase respiratory rate.

The most important factor in measuring blood pressure accurately is A. obtaining the reading in the early morning. B. using a cuff of the appropriate size for the patient. C. making sure the patient is comfortable and relaxed. D. removing clothing from the arm before applying the cuff.

B. Using the wrong cuff size for the patient will result in an erroneous reading. A cuff that is too small will result in a reading that is falsely high while a cuff that is too big will record a false low. One way to select a cuff is to make sure that the width of the cuff is 40% of the arm circumference where the cuff will be wrapped. The bladder (inside the cuff) should surround 80% of the arm circumference.

You recorded your patient's blood pressure as 166/88. Is this within the normal range for an adult? A. Yes. B. No.

B. While 120/80 mm Hg is considered a normal blood pressure for an adult, older adults may experience a rise as a result of decreased elasticity of the vessels; 140/90 is considered hypertension while a systolic pressure of 90 mm Hg or less is considered hypotension. In any case, 166/88 exceeds the normal range.

Peripheral Vascular Resistance (PVR)

BP = CO x PVR

Dorsal

Back

You have assessed a 45-year-old patient's vital signs. Which of the following assessment values requires immediate attention? A. An oral temperature of 100° F (37.8° C) B. A blood pressure of 148/88 mm Hg C. A respiratory rate of 30/min D. A radial pulse rate of 45 beats per 30 seconds

C. A respiratory rate of 30/min is above the normal range and indicates a respiratory problem that requires immediate attention. An adult breathing at that rate might be experiencing shortness of breath or dyspnea and, without intervention, this could become a life-threatening situation.

The patient's pulse rhythm is regular. You count her pulse A. for 15 seconds then multiply by 4. B. for 20 seconds then multiply by 3. C. for 30 seconds then multiply by 2.

C. It is appropriate to assess a pulse with a regular rhythm for 30 seconds and then multiply by 2 (since you will document the pulse rate per minute).

The proper technique for BP cuff inflation and deflation is A. rapid inflation followed by rapid deflation. B. slow inflation followed by slow deflation. C. rapid inflation followed by slow deflation. D. slow inflation followed by rapid deflation.

C. Rapid inflation helps ensure an accurate measurement of systolic pressure. Rapid deflation interferes with the accurate assessment of both systolic and diastolic readings. It is recommended that the pressure manometer gauge fall at a rate of 2 to 3 mm Hg per second.

You prepare to assess the patient's pulse and respiratory rate. You support her arm and palpate her wrist to locate the radial pulse along a groove located A. on the lateral aspect of the wrist. B. down the center of the wrist. C. on the thumb side of the wrist.

C. The radial artery lies in a groove that runs down the medial or thumb side of the wrist.

When auscultating a patient's apical pulse, you listen until you hear the S1 and S2 heart sounds clearly and regularly. S2 is produced when A. atria contract vigorously. B. ventricular walls vibrate. C. semilunar valves close. D. mitral valve snaps open.

C. The second heart sound, S2, is generated by the closure of the semilunar vales (the aortic and pulmonic valves) and signals the start of diastole. S2 is the "dub" heard in the normal "lub-dub" sound.

A 56-year-old female had her initial visit with a primary care provider (PCP) 2 weeks ago. At that appointment, her blood-pressure (BP) reading was above normal (160/90), so she returned today to have her BP evaluated. You escort the patient to an examination room and prepare to measure her vital signs, including temperature, pulse, respiration, and BP. You determine that the patient has not smoked or ingested any caffeine within the last 30 minutes. She is comfortably seated on the examining table. You prepare to check the patient's temperature using a tympanic thermometer. She denies any ear pain or drainage. You then inspect her ear canal for A. symmetry. B. sensitivity. C. cerumen.

C. The visible presence of earwax can minimize the amount of tympanic membrane the thermometer probe can access, thus altering the accuracy of the reading.

You are preparing to use a tympanic thermometer. Which of the following steps has the highest priority in the accurate use of this piece of equipment for measuring body temperature? A. Attaching the disposable probe cover B. Assessing the external ear for redness C. Gently pulling the pinna back and upward D. Replacing the thermometer in its charger

C. This position helps straighten the ear canal and provides optimal access to the tympanic membrane. Good contact with sufficient tympanic membrane is essential for an accurate tympanic temperature measurement.

To auscultate a patient's apical pulse accurately, you position the bell or the diaphragm of your stethoscope over the point of maximal impulse, which is located A. at the right midclavicular line. B. over the Angle of Louis. C. at the fifth intercostal space at the left midclavicular line. D. over the suprasternal notch.

C. To locate the point of maximal impulse, first locate the angle of Louis - a bony prominence just below the suprasternal notch. Slide your fingers down each side of the angle of Louis to locate the second intercostal space. Gently move your fingers down the left side of the sternum to the fifth intercostal space and laterally to the left midclavicular line. You have found the PMI.

When taking a patient's temperature rectally, it is important to A. rotate the probe gently if you encounter any resistance. B. insert the probe so that you are aiming at the patient's pelvic area. C. dip the probe about an inch to an inch and a half into a tube of lubricant. D. insert the probe about an inch and a half into the patient's anus.

D. An insertion depth of 1.5 inches (3.5 centimeters) ensures sufficient exposure of the probe to the blood vessels in the rectal wall. Postioning the probe against the blood vessels enables it to measure heat maximally and accurately.

When taking a patient's blood pressure, why is it important to notice the pressure on the manometer when you hear the fourth Korotkoff sound or phase? A. It corresponds to the patient's systolic pressure. B. You need it to record the second diastolic pressure. C. It is the loudest of the Korotkoff sounds. D. You might not hear a fifth Korotkoff sound.

D. Most clinicians consider the fifth Korotkoff sound, which is actually the disappearance of sound, an adult patient's diastolic blood pressure. However, with some patients, there is no distinct fifth sound. You hear sounds all the way to 0 mm Hg. For these patients, you would record the fourth Korotkoff sound as the diastolic blood pressure.

You are assess ing the vital signs of a newly admitted patient. To establish an accurate baseline of the patient's respiration, you A. instruct the patient to breathe in and to exhale out as he would normally. B. make the patient physically comfortable before beginning the assessment. C. determine if the patient has a history of any chronic respiratory problems. D. observe the patient's chest movements while appearing to assess his pulse.

D. You are most likely to observe the true respiratory pattern (rate, rhythm, and depth) when the patient is unaware that he is being assessed. When patients know their respiration is being observed, it is common for them to alter their respiratory pattern either voluntarily or involuntarily.

Palmer

Front

Heart Rate and Rhythm Documentation

HR=72 bpm RRR

Systolic Pressure

Maximum on contraction of left ventricle

When taking BP

Patient at rest for 5 minutes, arm free of clothing, arm supported at heart level, seated with back against chair, legs uncrossed, feet flat on floor

Diastolic Pressure

Pressure during resting phase of cardiac cycle

Respiration Documentation

RR 12 regular rhythm

RRR

Regular Rhythm and Rate

Pulse Pressure (PP)

Systolic - Diastolic = PP

Temperature Documentation

T=98.6 (O)

Pulse Deficit

The difference between apical and peripheral pulse rate. apical - radial = pulse deficit

Blood Pressure (BP)

The force of blood against arterial walls

BP cuff size

Too small = false high reading Too large = false low reading

Tachycardia

fast heart rate (>100 bpm)

Heart Rate Measu

number of beats within 30 seconds x2

Respiration Measurement

number of breaths within 30 seconds x2

Bradycardia

slow heart rate (<60 bpm)

Cardiac Output (CO)

stroke volume x heart rate = CO