Ch 8: Prep U

As a nursing student you learn that the normal range for an adult pulse is what?

60-100 bpm

When can the general inspection be started?

As soon as the examiner first sees the client

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

A 55-year-old bookkeeper comes to the office for a routine visit. The nurse notes that on a previous visit for treatment of contact dermatitis, the client's blood pressure was elevated. She does not have prior elevated readings, and her family history is negative for hypertension. The nurse measures her blood pressure in the office today. Which of the following factors can result in a false high reading?

Blood pressure cuff is tightly fitted.

A nurse obtains a pulse rate on an adult client of 56 beats per minute. What is the correct term that the nurse should use to document this finding?

Bradycardia

During the physical assessment of a client, a nurse observes that the client tends to lean forward and brace himself with his arms. The nurse recognizes this as a sign of what disease process?

Chronic pulmonary obstructive disease

Body temperature is not impacted by which of the following factors?

Diet

The nurse is performing vital signs during the routine assessment of an adult client who twisted his ankle during a mini-marathon. The client's pulse is 52 bpm. The nurse retakes the pulse; the finding is the same. The client tells the nurse that he has been training for 6 months for this mini-marathon. What should the nurse do in regard to this reading?

Document the finding

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

Hypertension Vasoconstriction Peripheral vascular disease

During general inspection, the examiner:

Integrates visual, auditory, and olfactory data

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 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

A nurse is filling out an incident report after an older adult patient fell while attempting to transfer from her bed to a commode. Which of the following health problems should the nurse consider when patient falls occur?

Orthostatic hypotension

A nurse finds a radial pulse that is weak and thready. What action should the nurse take next?

Palpate the carotid arteries

A patient rates the current pain level as being a 5 on the Numeric Rating Scale. How should the nurse document this pain assessment?

Patient rated pain level as being a 5 using the rating scale.

When assessing a client's respirations, what is most important to include in the documentation?

Presence of dyspnea

A nurse is assessing the pulse volume of a client with influenza. The nurse notes that the client has a thready pulse. Which of the following is a description of a thready pulse?

Pulse is felt with difficulty and disappears with slight pressure.

A nurse is assessing the blood pressure on an obese woman. What error might occur if the cuff used is too narrow?

Reading is erroneously high.

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

A nurse measures a client's blood pressure at 174/102 mm Hg. The nurse recognizes this as what classification of blood pressure measurement?

Stage 2 hypertension

The nurse is caring for a newly admitted adult client. When performing the general survey of this client, the nurse knows that accurate measurements provide critical information about what?

State of health

A student nurse assesses a blood pressure on an adult and finds it to be 140/86. What term is used for the top number (140)?

Systolic pressure

A 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

A nurse is assessing the blood pressure of a client using the Korotkoff's sounds technique. The nurse notes that the phase I sound disappears for 2 seconds. What should the nurse document on the progress record?

There is an auscultatory gap

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

A nurse has an order to take the core temperature of a patient. At which of the following sites would a core body temperature be measured?

Tympanic

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

oral: 37.0°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