HA prepU ch 5 vital signs

A nurse notes that the pulse rate of a client is less than 60 beats per minute. Which question is appropriate for the nurse to ask the client in regards to this finding?

"Have you been sitting for a long time?"

A nurse has an order to obtain orthostatic blood pressure readings on a client admitted with dehydration. The sitting blood pressure is 140/75mmHg. Which blood pressure reading with the client standing should the nurse recognize as orthostatic hypotension?

120/55 mmHg

The nurse has completed the initial assessment of a client and is now performing data analysis. The nurse obtained a blood pressure reading of 114/70 mm Hg. What is this client's pulse pressure?

44 mm Hg

A nurse is assessing the pulse rate of an athletic client during a routine checkup. The nurse should anticipate the pulse rate to be in what range of beats per minute?

45 to 60

A client's blood pressure while lying supine is recorded as 124/76 mmHg. The nurse records the client's pulse pressure as which of the following?

48 mmHg

The nurse obtains a client's blood pressure when standing and compares it to the measurement obtained while the client was sitting. The client's blood pressure when sitting was 122/72 mmHg. Which finding would suggest to the nurse that the client is experiencing orthostatic hypotension?

98/52 mm Hg

What population is at greatest risk for hypertension?

African Americans

When can the general inspection be started?

As soon as the examiner first sees the client

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

During a busy shift, Nurse R. admitted a postsurgical 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 high circumference. What are the potential consequences of Nurse R.'s action?

Nurse R. may obtain a blood pressure reading that is higher than actual blood pressure.

Assessment of the pulse amplitude is accomplished by which of the following?

Palpating the flow of blood through an artery

After teaching a group of students about blood pressure and Korotkoff's sounds, the instructor determines that the teaching was successful when the students identify which of the following?

Phase II sounds appear muffled and swishing.

The nurse is preparing to assess a client's vital signs. Which vital sign should the nurse assess first?

Temperature

Which of the following would the nurse need to keep in mind when assessing the blood pressure of a client who is receiving anticoagulant therapy?

The blood viscosity would be thinner, causing the blood pressure to decrease.

An 84-year-old man has been admitted to the emergency department from an extended care facility. Facility staff suspect that the client has pneumonia, and his malaise, productive cough, shortness of breath, and adventitious breath sounds are consistent with this diagnosis. However, the nurse's assessment of the client's vital signs yields an oral temperature of 97.5°F. How should the nurse best interpret this assessment finding?

The client's normothermic temperature does not rule out the presence of an infection.

The nurse is applying the blood pressure cuff on a client's arm. Which action would be most appropriate?

The cuff is placed about 1 inch above the antecubital area.

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

An older client's blood pressure is 148/60 mm Hg. What should this finding indicate to the nurse?

Undiagnosed cardiovascular disease

A nurse is obtaining a client's radial pulse. Which of the following actions demonstrates correct technique for this assessment?

Use of two middle fingers lightly applied to wrist area along the thumb side

The nurse is assessing a client's respiratory rate. Which of the following should the nurse do to ensure accuracy of this assessment?

Watch chest movement before removing the stethoscope after counting the apical beat

The nurse is assessing the skin condition and color of an African-American client. Which of the following would the nurse document as an abnormal finding?

ashen gray skin color

The nurse palpates a client's pulse and notes that the rate is 61 beats per minute, with an amplitude that is weak and thready. What would the nurse do next?

assess the client's pulse at the carotid site

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

a client's blood pressure is affected by

cardiac output, distensibility of the arteries, blood volume, blood velocity and viscosity.

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

diet

The nurse is reviewing the chart of a newly admitted client and identifies the client has Marfan syndrome. What assessment finding would the nurse expect to find?

elongated fingers

Which of the following conditions will lead to an increase in cardiac output?

exercise

Upon assessing a client who is hemorrhaging, the nurse is most likely to assess which compensatory change in vital signs?

increased pulse rate

Before completing the physical examination, the nurse determines that the client is awake, alert, and oriented. This information would be important for which part of the general survey?

level of consciousness

A client recovering from a stroke complains of pain. The nurse suspects this client is most likely experiencing which type of pain?

neuropathic

While caring for an 80-year-old client in his home, the nurse determines that the client's oral temperature is 35.8 °C (96.5 °F). The nurse determines that the client is most likely exhibiting

normal changes that occur with the aging process.

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 client 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

A nurse needs to measure the blood pressure of a client who has just undergone a bilateral mastectomy. How should the nurse measure the blood pressure?

over the clients thigh

In interviewing a client about his heart rate, the nurse asks whether he has noticed any alteration to his heartbeat. The client responds that he sometimes feels his heart race even when he has not been exerting himself physically. This alteration is known as which of the following?

palpitation

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

presence of dyspnea

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

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

client has a pulse rate of 28 beats/15 seconds. How should the nurse document this finding?

tachycardia

In which order should a nurse assess a client's vital signs?

temperature, pulse, respiration, blood pressure

A nurse obtains the blood pressure of a client who is uncharacteristically fatigued and who is lying in bed rather than sitting in a chair. The nurse should interpret the client's blood pressure reading in light of what principle?

the client's blood pressure will be slightly lower than standing readings