Chapter 24: Vital Signs

A client admitted with dehydration reports feeling dizzy with ambulation. What teaching would the nurse provide to the client?

"Dizziness when you change position can occur when fluid volume in the body is decreased."

The nurse's most recent assessment reveals that a patient's oral temperature is uncharacteristically elevated. What subsequent assessment question is most appropriate?

"Have you had anything to drink lately?" Hot beverages can artificially elevate a patient's oral temperature.

When taking the client's temperature, the student nurse will require further education when he states:

"The axillary route is the most accurate of all routes."

When assessing an infant's axillary temperature, it will be:

1°F (0.5°C) lower than an oral temperature.

A nurse attempts to count the respiratory rate for a client via inspection and finds that the client is breathing at such a shallow rate that it cannot be counted. What is an alternative method of determining the respiratory rate for this client?

Auscultate lung sounds, count respirations for 30 seconds, and multiply by 2.

Which peripheral pulse site is generally used in emergency situations?

Carotid The carotid artery is lightly palpated to obtain a pulse in emergency assessments, such as in a client in shock or cardiac arrest. The brachial pulse site is used for infants who have had a cardiac arrest.

Which client should not have a temperature assessed rectally?

Client with diarrhea

Which of the following sites results in measuring a client's core body temperature?

Rectal

A nurse is caring for an adult with fever. The nurse determines that which site is most ideal for obtaining the client's core body temperature?

Rectum

During measurement of a rectal temperature, the thermometer probe should be inserted about 1.5 inches (3.8 cm) in an adult and 0.5 inches (1.3 cm) in an infant.

True

An ultrasonic Doppler is used for:

auscultating a pulse that is difficult to palpate.

A nurse is assessing an apical pulse on a cardiac client. The client is taking digoxin. The nurse can anticipate that the digoxin will:

decrease the apical pulse.

The nurse is taking the apical pulse of a 6-month-old infant. Upon completion, the nurse tells the parent the baby's pulse is 140 beats per minute. The parent is concerned, stating, "That seems kind of high!" The nurse responds:

"I know it seems fast, but normal infant heart rates are 100-160 beats per minute."

What instructions should be provided to a newly diagnosed hypertensive client about home blood pressure monitoring? Select all that apply.

-Rest 3-5 minutes before taking your BP. -Take 3 measurements and average together. -Use a validated monitor with an automatic inflation cuff. The client taking his or her own BP at home should be taught to rest 3-5 minutes before taking the measurement, ideally taking 3 measurements at one sitting and averaging them together, and the client should be using a validated monitor with an automatic cuff. The client should be taught that the BP should be taken before they eat, when he or she is sitting down, and that the proper sized cuff should fit snugly but should allow one finger to be paced between the cuff and the arm.

A nurse is assessing clients in the emergency department for body temperature. Which nursing actions reflect proper technique when assessing body temperature by various methods? Select all that apply.

-When assessing an oral temperature with an electronic thermometer, place the probe beneath the client's tongue in the posterior sublingual pocket. -When assessing rectal temperature with an electronic thermometer, lubricate about 1 in (2.5 cm) of the probe with a water-soluble lubricant. -When assessing temperature with an electronic thermometer, hold the thermometer in place in the assessment site until a beep is heard. Placing the probe beneath the client's tongue in the posterior sublingual pocket when taking an oral temperature allows the probe to be in contact with blood vessels lying close to the surface, providing a more accurate reading. Lubricating approximately 1 in (2.5 cm) of the probe when assessing a rectal thermometer reduces friction and facilitates insertion, minimizing the risk of irritation or injury to the rectal mucous membranes. The beeping sound of the electronic thermometer indicates that the measurement is complete. A new probe is used for every client when using a tympanic thermometer, which prevents the need to wipe the probe with alcohol prior to inserting the probe into the client's ear. Chemical dot thermometers are kept in place for 3 minutes when taking an axillary temperature. Axillary temperatures are usually about 1°F (0.5°C) lower than the oral temperature and rectal temperatures are usually about 1°F (0.5°C) higher than the oral temperature.

Based upon circadian rhythms, when would the nurse note the highest temperature during a 24-hour period?

1700 Body temperature fluctuates throughout the day. Temperature is usually lowest around 0300 and highest from 1700 to1900.

A nurse is calculating the cardiac output of an adult with a stroke volume of 75 mL (75 × 109/L) and a pulse of 78 beats/min. What number would the nurse document for this assessment?

5,850 mL (5,850 × 109/L) Cardiac output is determined by multiplying the stroke volume by the heart rate/min, which equals 5,850 mL (5,850 × 109/L). Cardiac output and peripheral resistance determine both systolic and diastolic pressures.

A client is taking medications to treat a heart dysrhythmia. Which site should be used to assess the pulse in this client?

Apical An apical pulse is assessed when giving medications that alter heart rate and rhythm.

A nursing student is beginning a shift by taking a patient's vital signs. The student attempts to assess the patient's pulse at the radial site but is unable to locate this pulse. How should the nurse proceed with assessment?

Assess the patient's apical pulse using a stethoscope. It is not unusual to experience difficulty in palpating a peripheral pulse. If this is the case, the student should attempt to auscultate the pulse at the patient's apex. There is no obvious need to report this finding immediately. The dorsalis pedis and posterior tibial sites are not normally used for determining heart rate. Manual assessment is more accurate than automated assessment.

An obese client has developed peripheral edema as a consequence of heart failure, making it very difficult for the student nurse to accurately palpate the client's peripheral pulses. How should the nurse proceed with this assessment?

Auscultate the client's apical pulse.

A nurse is assessing the respirations of a 60-year-old female client and finds that the client's breaths are so shallow that the respirations cannot be counted. What would be the appropriate initial nursing intervention in this situation?

Auscultate the lung sounds and count respirations. If the respirations are too shallow to count it is easier to count respirations by auscultating the lung sounds. The nurse should auscultate lung sounds and count respirations for 30 seconds, then multiply by 2 to calculate the respiratory rate per minute. If the respiratory rate is irregular, the nurse should count for a full minute. The nurse notifies the physician of the respiratory rate and the shallowness of the respirations following assessment. Pain typically causes vital signs to elevate. The nurse cannot administer oxygen without a physician's order.

Normal vital sign ranges for the average healthy adult while resting are: (google)

Blood pressure: 90/60 mm Hg to 120/80 mm Hg. Breathing: 12 to 18 breaths per minute. Pulse: 60 to 100 beats per minute. Temperature: 97.8°F to 99.1°F (36.5°C to 37.3°C)/average 98.6°F (37°C)

A nurse is assessing an apical pulse on a cardiac client. The client is taking digoxin, which is a cardiac medication. The nurse can anticipate that the digoxin will do what?

Decrease the apical pulse. Some cardiac medications, such as digoxin, whose action is specific to the work of the heart, slow the heart rate while also strengthening the force of contraction to increase cardiac output.

A person's core body temperature is highest in the early morning and lowest in the late afternoon.

False

Which term is not used to describe the quality of a person's pulse?

Galloping

A nursing student is manually taking the client's blood pressure. Which step will demonstrate the correct way of inflating the blood pressure cuff?

Inflate the cuff to 30 mm Hg above reading where brachial pulse disappeared. Inflating cuff to 30 mm Hg above reading where brachial pulse disappeared ensures accurate assessment of systolic blood pressure.

The nurse is assessing the apical pulse of a client using auscultation. What action would the nurse perform after placing the diaphragm over the apex of the heart?

Listen for heart sounds.

A nurse needs to measure the blood pressure of a client with an electronic manometer. Which of the following advantages does an electronic manometer provide over an aneroid manometer or mercury manometer?

No stethoscope is required. An electronic manometer eliminates the need for a stethoscope. However, an electronic manometer requires a calibration check and readjustment every 6 months, unlike a mercury manometer which does not require readjustment. An electronic manometer is expensive depending on quality when compared to an aneroid manometer. A nurse can read the gauge of an aneroid manometer, not an electronic manometer, from any direction.

During a busy shift, Nurse R. admitted a postoperative client who is obese. Nurse R. used the standard size of blood pressure cuff available on the unit, despite the fact that the client's upper arms have a large circumference. What are the potential consequences of Nurse R.'s action?

Nurse R. may obtain a blood pressure reading that is higher than the actual blood pressure. If a blood pressure cuff is too narrow, the reading could be erroneously high because the pressure is not evenly transmitted to the artery. This occurs when an average-sized cuff is used on an obese person. This mismatched cuff will not, however, make it particularly difficult to inflate the cuff and brachial occlusion is not a significant risk.

The nurse places a client experiencing labored breathing in an upright position. The nurse notes that the client is able to breathe more easily in this upright position and documents this condition on the chart as:

Orthopnea Dyspneic people can often breathe more easily in an upright position, a condition known as orthopnea, because sitting or standing allows gravity to lower organs from the abdominal cavity away from the diaphragm. Bradypnea is a decrease in respiratory rate. Tachypnea is an increased respiratory rate. Apnea refers to periods during which there is no breathing.

The nurse is preparing to assess a rectal temperature on an adult client. What is the appropriate nursing intervention?

Provide privacy for the client.

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.

Which term indicates a potentially serious client condition?

Pyrexia Pyrexia means an increase above normal in body temperature. Pulse pressure is an objective term related to the pulse. Eupnea means a normal breathing pattern. Afebrile means that the body temperature is not elevated.

The nurse is taking a rectal temperature on a client who reports feeling lightheaded during the procedure. What would be the nurse's priority action in this situation?

Remove the thermometer and assess the blood pressure and heart rate. Vagal nerve stimulation may occur when obtaining a rectal temperature. Vagal nerve stimulation can cause the pulse and blood pressure to drop significantly, causing the client to feel lightheaded; therefore, the thermometer should be removed immediately and the pulse and blood pressure assessed. The physician can be called after assessing the client. The temperature is not the priority at this time. Assistance for CPR would be determined if the client's condition worsens.

A client that has been taught to monitor her pulse calls the nurse because she is having difficulty feeling it strongly enough to count. She states that she takes her pulse before taking her cardiac medication. She sits down with her nondominant arm on a firm service, palm up. She uses her three fingers to feel just below the wrist on the side closest to the body. She does not press hard and she has a watch with a second hand to use to count it, but she has a very difficult time feeling it. What does the nurse recognize that she is doing wrong?

She should place her three fingers just below the wrist on the outside of the arm with the palm up. A client is taught to take his or her own pulse before certain medications or after exercise, depending on the individual client's needs. When teaching a client to take his or her own pulse, the nurse should teach the client to sit down and place an arm on a hard service with the palm upward. Then using three fingers, the client should feel just below the wrist on the outer side of the arm for the pulse. The client should be taught not to press too hard or the pulse can be obliterated and to use a watch or clock with a second hand to count the pulse.

The nurse has completed an assessment of a patient's vital signs, all of which are within the patient's norms except for the patient's elevated blood pressure. Before leaving the patient's bedside, the nurse should perform what action?

Tell the patient his blood pressure and provide necessary teaching.

The nurse is checking the client's temperature. The client feels warm to touch. However, the client's temperature is 98.8°F (37.1°C). Which statement could explain this?

The client is covered with a couple of thick blankets. Ordinarily, changes in environmental temperatures do not affect core body temperature, but core body temperature can be altered by exposure to hot or cold extremes. The degree of change relates to the temperature, humidity, and length of exposure. The body's thermoregulatory mechanisms are also influential, especially in infants and older adults who have diminished control mechanisms. Death may occur if a person's core body temperature drops to 25°C (77°F) or rises to 45°C (113°F).

When administering beta blocker medications, the physician adds an order to hold medication when the client is bradycardic. Which statement explains this order?

The client's pulse rate is below 60 beats per minute. An abnormally slow pulse rate is called bradycardia. In adults, a pulse rate below 60 beats per minute is considered bradycardic. Bradycardia may be the normal resting heart rate in a trained athlete. Disease of the SA node may result in bradycardia because of poor impulse formation. In addition, enhanced parasympathetic nervous system activity (e.g., stimulation of the carotid sinus) may cause bradycardia.

The nurse is teaching the parents of an infant with an irregular heartbeat how to check the pulse rate. The infant's pulse is very high and irregular. What will the nurse have to do in order to teach these parents how to monitor their infant's pulse rate?

The parents will have to be taught how to use a stethoscope so that they can listen to and count the infant's apical pulse.

A nurse is assessing the blood pressure of a client using the Korotkoff sound 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. An auscultatory gap is a period during which sound disappears. An auscultatory gap can range as much as 40 mm Hg. A widening in the diameter of the artery takes place in the phase II of the Korotkoff sound technique. An adult diastolic pressure takes place in the phase IV of the Korotkoff sound technique.

A 62-year-old female client being treated for hypertension did not take her daily BP medication over the weekend because she was out of medication and the pharmacy was closed. Her average home blood pressure monitoring (HBPM) reading has been 130/82. Today her BP has been 138/90, 135/85, and 142/86. She calls the on-call nurse for her health care provider. What is the most appropriate thing for this nurse to advise this client?

To take the recommended daily dose of medication and call the health care provider if the average of her HBPM readings increase/decrease by 10, or if she has any other concerns. HBPM readings are the ideal method for monitoring response to treatment for high BP. This client's average BP after not taking her medication is 138/87 and is NOT 10 more than what her HBPM reading has been. Clients should be taught when performing HBPM that they should call the health care provider if the averages of HBPM readings increase/decrease by 10, or if she has any concerns. The client should not be told to take double the dose of medication or to take the doses she missed; this is unsafe advice without consulting a health care provider.

The student nurse is having difficulty feeling the pedal pulse of the client with a fractured leg. What should the nurse do next?

Use the Doppler ultrasound device.

Clients demonstrating apnea have what?

a temporary cessation of breathing

The nurse is preparing to assess a client's oral temperature. The nurse should plan to place the thermometer probe in which area of the client's mouth?

deep in the posterior sublingual pocket

Which of the following pathologic conditions would result in release of ADH by the posterior pituitary?

hemorrhage ADH is released from the posterior pituitary when stimulated by decreased blood volume and blood pressure (such as with hemorrhage) or increased osmolarity of the blood. Its effect is to retain water to increase circulatory fluid volume and, in turn, increase blood pressure. ADH release is not stimulated by allergies, obesity, or asthma.

Body temperature regulation occurs in a part of the brain known as the:

hypothalamus The hypothalamus, located in the pituitary gland in the brain, is the body's built-in thermostat.

The temperature is 102°F (39°C) during a heat wave. The nurse can expect admissions to the emergency room to present with:

increased temperature. Body temperature can fluctuate with exercise, changes in hormone levels, changes in metabolic rate, and extremes of external temperature.

Which outcome best reflects achievement of the goal, "The client will demonstrate correct steps in taking his own pulse rate"?

palpation of the radial pulse on the thumb side of the inner aspect of the wrist.

A nurse is assessing the blood pressure of a team of healthy athletes at the heath care facility. Which observation 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. Measuring the blood pressure does not help in assessing the thickness of blood, oxygen level in the blood, or the volume of air entering the lungs.

A pulse deficit is the difference between:

the apical pulse and the radial pulse rates. When a pulse deficit is present, the radial pulse is always lower than the apical pulse rate.