Chapter 30

An individual contacts the emergency department of the local hospital to ask what to do for a skiing partner who appears to be suffering from hypothermia. The victim is alert and able to respond to questions. The nurse instructs the individual who has called to have the victim: 1. Take sips of brandy 2. Drink a bowl of warm soup 3. Drink a cup of very hot coffee 4. Run the affected extremities under hot water

2

The appropriate site for taking the pulse of a 2-year-old is: 1. Radial 2. Apical 3. Femoral 4. Pedal

2

The client comes to the emergency department after having been in the sun for an extended period of time. The nurse also determines that the client is taking a diuretic. Heatstroke is suspected and the nurse observes for: 1. Diaphoresis 2. Confusion 3. Temperature of 36 C 4. Decreased heart rate

2

A client is being monitored with pulse oximetry. On review of the following factors, the nurse suspects that the values will be influenced by: 1. The placement of the sensor on the extremity 2. A diagnosis of peripheral vascular disease 3. A reduced amount of artificial light in the room 4. The increased ambient temperature of the client's room

2

The nurse measures the blood pressure in the leg due to the fact that the client has bilateral casts on the upper extremities. The nurse palpates the pulse before the measurement at the: 1. Popliteal fossa behind the knee 2. Inner side of the ankle below the medial malleolus 3. Top of the foot between the extension tendons of the great toe 4. Inguinal ligament midway between the symphysis pubis and the anterior superior iliac spine

1

A false high blood pressure reading may be assessed, as the nurse explains to the nurse assistant, if the assistant: 1. Wraps the cuff too loosely around the arm 2. Deflates the blood pressure cuff too quickly 3. Repeats the blood pressure assessment too soon 4. Presses the stethoscope too firmly in the antecubital fossa

1

A nurse administers pain medication for a client complaining of pain. The nurse first assesses vital signs and finds them to be as follows: blood pressure, 134/92 mm Hg; pulse, 90 beats per minute; respirations, 26 breaths per minute. The nurse's most appropriate action is to: 1. Give the medication 2. Ask if the client is anxious 3. Check the client's dressing for bleeding 4. Recheck the client's vital signs in 30 minutes

1

After measuring the client's vital signs, the nurse obtains the following results: blood pressure = 180/100 mm Hg, pulse = 82 beats/min, R = 16 breaths/min, and rectal temp = 37.5° C. The nurse should: 1. Retake the blood pressure 2. Retake the client's temperature 3. Report all of the findings immediately 4. Record the findings as within normal limits

1

An 84-year-old client with diabetes is admitted for insulin regulation. Which of the following blood pressure, pulse, and respiration measurements, respectively, is considered to be within the expected limits for a client of this age? 1. BP = 138/88 mm Hg, P = 68 beats/min, R = 16 breaths/min 2. BP = 104/52 mm Hg, P = 68 beats/min, R = 30 breaths/min 3. BP = 108/80 mm Hg, P = 112 beats/min, R = 15 breaths/min 4. BP = 132/74 mm Hg, P = 90 beats/min, R = 24 breaths/min

1

The client is seen in the emergency center for heat exhaustion as a result of exposure. The nurse anticipates that treatment will include: 1. Replacement of fluid and electrolytes 2. Initiation of oral antibiotic therapy 3. Application of hypothermia wraps 4. Alcohol sponge baths

1

The nurse appropriately instructs trained ancillary personnel to use an electronic blood pressure cuff to take the blood pressure of which of the following clients? 1. A 25-year-old who was admitted for alcohol detoxification 2. A 69-year-old diagnosed with Parkinson's disease 5 years ago 3. A 57-year-old placed on antihypertensive medication therapy 2 months ago 4. An 80-year-old client whose systolic BP is routinely assessed in the high 80s

1

The nurse enters the room to measure the client's pulse rate. The nurse recognizes that the client's rate may be increased as a result of: 1. A febrile condition 2. Administration of digoxin 3. The client's athletic conditioning 4. Unrelieved severe postoperative pain

1

The nurse has asked the assistive personnel to take the blood pressure of a client who experienced a left mastectomy 3 days ago. Which of the following statements by the assistive personnel shows the best understanding regarding the appropriate assessment technique for this particular client? 1. "Is there anything affecting her right arm?" 2. "Has she been experiencing any edema in that left arm?" 3. "How long has it been since she had her breast removed?" 4. "I'll wait until she's been medicated for pain before I take it."

1

The nurse has assessed a client's blood pressure (BP) using the left thigh because of bilateral upper arm casts. The client's precasting left arm BP was 108/70 mm Hg. The nurse expects the present BP reading to be: 1. 10-40 mm Hg higher systolic pressure than before the casting 2. 5-10 mm Hg higher reading in both systolic and diastolic pressures 3. Representative of the original baseline established before the casting 4. A slight decrease in the diastolic pressure when compared to precasting pressure

1

The nurse is assisting the wife of a client who has been diagnosed with hypertension to monitor his blood pressure. The nurse states that the blood pressure should be taken: (Select all that apply.) 1. At the same time each day 2. On the same arm each time 3. In the same position each time 4. After the client has had a brief rest 5. After his blood pressure medication 6. Right before getting up in the morning

1,2,3,4

The nurse is discussing risk factors for hypertension with family members attending a self-help group meeting for clients in cardiac rehabilitation. Which of the following statements made by the nurse are relevant to this discussion on prevention of this disorder? (Select all that apply.) 1. "Low fat foods are your blood pressure's best friend." 2. "Have your triglyceride's checked on a regular basis." 3. "Ideal weight is ideal for keeping blood pressure under control." 4. "Nicotine is a no-no when attempting to control blood pressure." 5. "If they are prescribed, take your blood pressure medicine as suggested." 6. "Keep alcohol consumption down and your blood pressure will be down."

1,2,3,4,6

Which of the following factors make using a pulse oximeter on an elderly client challenging? (Select all that apply.) 1. Possibility of decreased cardiac output 2. Potential for peripheral vascular disease 3. Existence of decreased red blood cell count 4. Uncooperative behavior related to senility 5. Inability to comprehend rationale for monitoring 6. Vasoconstriction related to impaired heat regulation

1,2,3,6

The nurse is discussing the correct technique for taking a blood pressure with clients and their caregivers. Which of the following nursing statements would appropriately identify the most likely causes for experiencing difficulty actually hearing the blood pressure? (Select all that apply.) 1. "The cuff cannot be too small or too big." 2. "Don't release the air out of the cuff to quickly." 3. "Keep the arm you are using at the level of the heart." 4. "If you are having difficulty, try taking it in the other arm." 5. "The stethoscope needs to be placed directly over a pulse point." 6. "Remember to pump up the cuff until you can no longer feel the pulse."

1,2,5,6

The nurse appropriately instructs trained ancillary personnel to avoid using an electronic blood pressure cuff to take the blood pressure of which of the following clients? 1. A 25-year-old who was admitted for depression and anxiety 2. A 69-year-old diagnosed with Parkinson's disease 5 years ago 3. A 57-year-old prescribed antihypertensive medication 6 weeks ago 4. An 80-year-old client whose systolic BP is routinely assessed in the low 90s

2

The nurse has assigned nursing assistive personnel to obtain the blood pressures on the unit's clients. Which of the following statements made by the assistive personnel shows the best understanding regarding appropriate communication of the BP readings? 1. "I'll ask the clients what their blood pressure usually runs." 2. "I'll give you a list of all the readings I get before I chart them." 3. "I'll chart the results and let you know whose pressure is high." 4. "I'll recheck any pressure that seems higher than their normal."

2

The nurse has assigned the vital signs of the elderly clients residing in the facility's assisted living unit to the nursing assistant. Which of the following statements made by the ancillary personnel requires immediate correction by the RN? 1. "As you age your blood pressure may go up, but it doesn't have to if your vessels are healthy." 2. "If anyone's oral temperature is over 100° F, I'll let you know right away since that means they have a fever." 3. "I always wait a good 30 minutes after returning the older client back to bed before I count their pulse." 4. "I watch the elderly client's stomach and count the number of times it rises when I am counting respirations."

2

The nurse has just taken vital signs for a 30-year-old client. Based on the results, the nurse will report the following finding that is out of the expected range for a client of this age: 1. T = 37.4° C 2. P = 110 beats/min 3. R = 20 breaths/min 4. BP = 120/76 mm Hg

2

The nurse is assessing a client's blood pressure to establish a baseline. The pressure in the right arm is 12 mm Hg lower than that in the left arm. The nurse most appropriately realizes that these data: 1. Reflect a normal variation 2. Should be reported to the client's health care provider 3. Dictate that pressure should be monitored in the left arm 4. Indicate that the client may be experiencing vascular problems

2

The nurse is assessing an elderly client's blood pressure during a routine visit. When asked, the client volunteers that when he took his pressure at home yesterday it was 126/72 mm Hg. The nurse determines that the client's pressure today is 134/70 mm Hg. The nurse recognizes that the most likely cause of the elevation is: 1. The difference between the monitoring equipment being used 2. The client may be experiencing mild anxiety regarding the check-up 3. The effects of aging on the client's ability to hear the first Korotkoff sound 4. The client is not inflating the cuff sufficiently to detect the systolic pressure

2

The nurse recognizes that which of the following clients present at the annual July 4th marathon is at greatest risk for hyperthermia and the resulting heatstroke? 1. A 34-year-old running for the first time in the July 4th marathon who is sweating profusely 2. A 16-year-old volunteer, with type 1, insulin-dependent diabetes, who is checking runners in for the marathon at the starting gate 3. A 75-year-old who is prescribed medication for Crohn's disease and who is sitting outdoors watching her granddaughter run the marathon 4. A 55-year-old diagnosed with bipolar disease and prescribed a phenothiazine (Serentil), who will be walking the marathon course

2

The nurse recognizes that which of the following clients present at the annual July 4th marathon is showing the most compelling signs of hyperthermia and the resulting heatstroke? 1. The 75-year-old who has forgot where the car is parked 2. The 16-year-old volunteer whose skin appears sunburned but dry 3. The 34-year-old who finished the race and is reporting leg cramps 4. The 55-year-old observer who complains of nausea and being thirsty

2

Which of the following sites is best suited for measuring oxygen saturation (pulse oximetry)? 1. A polished ring finger of a client with pneumonia whose nail capillary refill time is 2.5 seconds 2. A pierced earlobe of a client with a closed head injury whose nail capillary refill time is 3.5 seconds 3. The ring finger of a client with Parkinson's disease that has a capillary refill time of less than 3 seconds 4. An earlobe of a client who is experiencing moderate diaphoresis with a nail capillary refill time of 3.5 seconds

2

While the nurse is taking the client's blood pressure, the client asks if the reading is high. In accordance with the newest guidelines, the nurse informs the client that a blood pressure measurement that is consistent with hypertension is: 1. 120/70 mm Hg 2. 130/84 mm Hg 3. 120/78 mm Hg 4. 118/80 mm Hg

2

The nurse is discussing the proper technique for obtaining an accurate blood pressure reading with assistive nursing personnel. Which of the following statements reflect techniques that will minimize the risk of a false high systolic reading? (Select all that apply.) 1. "Slowly deflate the pressure from the cuff." 2. "Wrap the cuff snuggly around the client's arm." 3. "Always support the client's arm at the level of the heart." 4. "Be sure that the cuff is wide enough for the client's arm." 5. "Allow the arm to rest before repeating the blood pressure." 6. "Make sure your stethoscope is fitted in your ears appropriately."

2,3,4,5

The nurse is providing a health promotion session regarding the factors that contribute to heatstroke for members of a college cross-country running team. Which of the following statements should the nurse include in the discussion? (Select all that apply.) 1. "Take frequent breaks to rest out of the sun." 2. "The greater the humidity, the greater the hazard." 3. "Wear clothing that will absorb the perspiration." 4. "The higher the temperature, the higher the risk." 5. "The more fluids you drink, the fewer chances you take." 6. "Pay attention to pacing yourself when it's hot and muggy."

2,4,5,6

A client has developed pneumonia, and his temperature has increased to 37.7° C. The client is shivering and "feels uncomfortable." The nurse should: 1. Apply hot packs to the axilla and groin 2. Wrap the client's four extremities 3. Restrict oral fluid consumption 4. Apply a hypothermia mattress

3

A client has just gotten out of bed to go to the bathroom. As the nurse enters the room, the client says, "I feel dizzy." The nurse should: 1. Go for help 2. Take the client's blood pressure 3. Assist the client into a sitting position 4. Tell the client to take several deep breaths

3

The client appears to be breathing faster than before. The nurse should: 1. Ask the client if he has felt stressful 2. Have the client lay down on the bed 3. Count the client's rate of respirations 4. Palpate the client's own radial pulse

3

The client is identified by the nurse as having a remittent fever. The student asks what that means and the nurse explains that a remittent fever is: 1. A constant body temperature above 100.4° F with little fluctuation 2. Spikes that are interspersed with normal temperatures within 24 hours 3. Spikes and falls in temperature, but temperature does not return to the normal limits 4. Periods of febrile episodes interspersed with normal body temperatures

3

The client's apical pulse will be taken by a student. According to the nurse the stethoscope should be placed along the left clavicular line at the: 1. Second to third intercostal space 2. Third to fourth intercostal space 3. Fourth to fifth intercostal space 4. Fifth to sixth intercostal space

3

The nurse has assigned nursing assistive personnel to obtain the blood pressures on the unit's clients. Which of the following statements made by the assistive personnel shows the greatest need for additional instruction regarding appropriate communication of the BP readings? 1. "I'll give you a list of all the readings after I chart them." 2. "May I ask the clients what their blood pressure usually runs?" 3. "I'll chart the results and let you know whose pressure is running high." 4. "Do you want me to take the readings before they get their medications?"

3

The nurse has assigned nursing assistive personnel to obtain the temperatures on the unit's clients. Which of the following statements made by the assistive personnel shows the greatest need for additional instruction regarding appropriate temperature monitoring orally? 1. "Are all the clients cooperative enough to take the temperatures orally?" 2. "Do you want me to take the temperature tympanically on everyone?" 3. "I'll wait until breakfast is over so I won't distract them from eating." 4. "I'll chart the results and let you know whose temperature is running high."

3

The nurse is using a manual cuff to assess the blood pressure of a client experiencing hypertension. To best ensure accommodation for a possible auscultatory gap, the nurse should use which of the following as a guide for inflating the cuff appropriately? 1. Review the client's chart for his last blood pressure reading. 2. Ask the client what his typical blood pressure reading is when taken manually. 3. Inflate 30 mm Hg higher than where the radial pulse can no longer be palpated. 4. Take the client's blood pressure both sitting and standing and use the higher reading.

3

The nurse is working in the newborn nursery. In planning for temperature measurement, the nurse will obtain the reading on the infants by using the: 1. Oral site 2. Rectal site 3. Axillary site 4. Tympanic site

3

The student nurse is assessing the vital signs of a 10-year-old client. The expected values for a client of this age are: 1. P = 140 beats/min, R = 50 breaths/min, BP = 80/50 mm Hg 2. P = 100 beats/min, R = 40 breaths/min, BP = 90/60 mm Hg 3. P = 80 beats/min, R = 22 breaths/min, BP = 110/70 mm Hg 4. P = 60 beats/min, R = 12 breaths/min, BP = 160/90 mm Hg

3

When using a glass thermometer at home to accurately assess axillary temperature, the nurse should tell the parent of a 1 1/2-year-old child to: 1. Hold the thermometer at the bulb end 2. Cleanse the thermometer in hot water 3. Assess the thermometer for 5 minutes 4. Allow the child to hold the thermometer

3

A 6-year-old boy has just eaten a grape popsicle and the nurse is ready to take vital signs. An appropriate action would be to: 1. Take the rectal temperature 2. Take the oral temperature as planned 3. Have the child rinse out the mouth with warm water 4. Wait 20 minutes before assessing the oral temperature

4

A construction worker is seen in the emergency department with low blood pressure, normal pulse rate, diaphoresis, and weakness. These are clinical signs of: 1. Heatstroke 2. Heat cramp 3. Hypothermia 4. Heat exhaustion

4

A spouse assists the nurse evaluating the measurement of the client's blood pressure. The nurse feels additional teaching is required if the spouse is observed: 1. Deflating the cuff at 2 mm Hg/second 2. Having the client sit down for the measurement 3. Using the same time each day for the measurement 4. Taking the blood pressure after the client comes back from a walk

4

The client has bilateral casts on the upper extremities, so the nurse will be measuring the blood pressure in the leg. The nurse expects the diastolic pressure to be: 1. 10 to 40 mm Hg higher than in the brachial artery 2. 20 to 30 mm Hg lower than in the brachial artery 3. 40 to 50 mm Hg higher than in the brachial artery 4. Essentially the same as that in the brachial artery

4

The client is febrile, and the temperature needs to be reduced. The nurse anticipates that treatment will include: 1. An alcohol and water bath 2. Ice packs to the axillae and groin 3. Tepid, plain water sponge down 4. Application of a cooling blanket

4

The nurse is alert to which of the following factors that lowers the blood pressure? 1. Stress-producing anxiety 2. Heavy alcohol consumption 3. Cigarette, cigar, or pipe smoking 4. Prescribed diuretic administration

4

The postoperative vital signs of an average size adult client are: BP = 110/68 mm Hg, P = 54 beats/min, R = 8 breaths/min. The client appears pale, is disoriented, and has minimal urinary output. The nurse should: 1. Retake the vital signs in 30 minutes 2. Continue with care as planned 3. Administer a stimulant 4. Notify the physician

4

Upon entering the room, the nurse notes that the client has an irregular respiratory rate, with periods of apnea and increases in respiration, followed by a reversal of the pattern. The nurse reports this respiratory assessment as: 1. Biot's respirations 2. Kussmaul's respirations 3. Hyperpneic respirations 4. Cheyne-Stokes respirations

4

2. A 74-year-old client currently has a temperature reading of 36° C. The client walks 1 mile every day and takes naps during the day. Which of the following is most likely the reason for the lowered body temperature? A. The lowered temperature is a natural result of the aging processes. B. Increased stress from exercise has probably reduced the temperature. C. The individual circadian rhythm requiring daytime naps lowers the temperature. D. Hormone levels are the most probable cause of the hypothermic condition

A

3. A construction worker comes to the emergency room with low blood pressure, normal pulse, cool skin temperature, diaphoresis, and weakness. These are clinical signs of: A. Heat exhaustion B. Heat stroke C. Heat cramp D. Hypothermia

A

An 84-year-old diabetic client is admitted for insulin regulation. Which of the following blood pressure, pulse, and respiration measurements, respectively, is considered within the expected limits for this client? A. 148/90, 68, 16 B. 94/52, 68, 30 C. 108/80, 112, 15 D. 132/74, 90, 24

A

. Which of the following is an appropriate site for taking the pulse of a 2-year-old? A. Radial B. Apical C. Femoral D. Pedal

B

The client begins to breathe rapidly. The nurse should: A. Ask the client if there have been any stressful visitors B. Measure the oxygen saturation level C. Count the rate of respirations D. Take the radial pulse

B

. A client complains of pain and asks the nurse for pain medication. The nurse first assesses vital signs: blood pressure, 134/92; pulse, 100; and respiration 32. The nurse's most appropriate action is to: A. Ask if the client is anxious B. Check the client's dressing for bleeding C. Give the medication D. Recheck the client's vital signs in 30 minutes

C

4. The nurse is ready to take vital signs on a 6-year-old child. The child has just enjoyed a grape popsicle. An appropriate action would be to: A. Take the rectal temperature B. Take the oral temperature as planned C. Have the child rinse out the mouth with warm water D. Wait 30 minutes and take the oral temperature

D

A client has developed pneumonia and his temperature has increased to 37.7C. The client is shiver and feels uncomfortable. Which of the following is true concerning the physiology of heat production in this client? A. Increased BMR is probably causeing the febrile condition B. Encouraging the client to ambulate would help decrease heat production C. The shivering is likely the cause of the increased temperature D. The client may need to consume more nutrients during the febrile condition

D

If measuring blood pressure is necessary in the leg, the nurse expects the diastolic pressure to be: A. 10 to 40 mm Hg higher than in the brachial artery B. 20 to 30 mm Hg lower than in the brachial artery C. 50 mm Hg higher than in the brachial artery D. Essentially the same as that in the brachial artery

D

The client's pulse is 72/minute, easily palpated. In addition, the pedal pulses are equal in strength in both feet. To best assess for an irregularity in the pulses, the nurse should: A. Determine the rate of the pedal pulses B. Auscultate for the strength of the apical pulse C. Examine the electrocardiogram's reading D. Ask the client if there is a pulsation that is abnormal

D