NUR 201 - Jensen Ch. 5

The nurse notes that a client is grimacing. What can the nurse ask the client to determine the cause of this facial expression?

"Are you currently experiencing any pain?"

Which general survey question focuses on the common "fifth vital sign"?

"Are you experiencing any pain right now?"

A nurse is completing a general survey of a client's health and is beginning by measuring the client's vital signs. What assessment question constitutes the "fifth vital sign"?

"Are you having any pain right now?"

The nurse is caring for a client who is having nothing by mouth (NPO) on the first postoperative day. The client's blood pressure was 120/80 mm Hg approximately 4 hours ago, but it is now 140/88 mm Hg. The nurse should ask the client which of the following questions?

"Are you having pain from your surgery?"

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 at an ambulatory clinic is preparing to begin the collection of objective assessment data from a female client. After meeting the client and bringing her into the examination room, what instruction should the nurse provide?

"Please have a seat on the edge of the exam table."

The nurse has assisted a 74-year-old woman from a chair to the examination table during an assessment, and the nurse observes that the client moves particularly slowly and stiffly. The nurse should question the client regarding a possible history of what health problem?

Arthritis

When can the general inspection be started?

As soon as the examiner first sees the client

The nurse is completing the assessment of a client who takes a beta-adrenergic blocker and a diuretic. Which assessment would be most important for the nurse to complete to ensure safety with a client receiving antihypertensive agents?

Evaluating for orthostatic hypotension

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

Exercise

The client is exercising. The nurse understands that exercise has what effect on the body? Select all that apply.

Increased heart rate Increased blood pressure Increased cardiac output

A nurse in the ED is assessing an adult client involved in a motor vehicle collision. What findings during the assessment would indicate that the situation is acute? Select all that apply.

Pallor Extreme anxiety Change in mental status

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

Palpating the flow of blood through an artery

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

A nurse observes the gait of an elderly client admitted for surgery. The client's gait is stiff with rigid movements. The nurse should ask this client questions about which disease?

Parkinson's disease

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.

A nurse in the surgical daycare department has called a client in from the waiting room and is meeting the client for the first time. The nurse immediately observes that the client has a noticeably "stooped" posture. How should the nurse best follow up this abnormal assessment finding?

Perform a focused assessment of the client's musculoskeletal system

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.

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

Presence of dyspnea

A nurse assesses a female client's core body temperature and finds that she has a slightly elevated temperature. Which of the following factors could explain this finding? Select all that apply.

The client just finished exercising. The client is ovulating. The client is stressed.

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.

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 an elderly postsurgical client in the home. To begin the physical examination, the nurse should first assess the client's

vital signs.

When obtaining an oral temperature on a client, the nurse inserts the thermometer:

Deep in the posterior sublingual pocket

A female client is admitted to the health care facility due to reports of decreased appetite, loss of sleep, feelings of being unsafe in her own home, and inability to concentrate. She appears pale; hair disheveled, no makeup, and will not make eye contact. Based on this data, which nursing diagnosis can the nurse confirm?

Depression

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

Diet

Which of the following factors affect blood pressure? Select all that apply.

Ethnicity Smoking Weight Stress

The nurse assesses the amplitude of the client's radial pulse and finds it to be weak and diminished. Which of the following scores should the nurse record?

1+

The nurse reviews temperature measurements for assigned clients. Which measurement should the nurse identify as being elevated?

100.5 F rectal

During the first assessment of the client, the nurse assesses the blood pressure in both arms. Which of the following findings is an acceptable variation?

118/78 mm Hg in the right arm and 122/80 mm Hg in the left arm

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

120/55 mm Hg

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

A nurse is assessing the respiratory rate of an elderly client. Which of the following findings in breaths per minute would indicate a normal respiratory rate in this client?

18

A nurse should anticipate the normal respiratory rate of an elderly client to be how many breaths per minute?

18 breaths/min

During an initial assessment of a new patient, the nurse notes that the patient's weight is 210 lb and his height is 6'0". What is the patient's body mass index (BMI)?

28.5

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 nurse assesses 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?

45-60

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

A nurse has assessed the blood pressure of a recently admitted client and obtained a reading of 128/78 mm Hg. What is this client's pulse pressure?

50 mm Hg

A nurse has assessed the blood pressure of a recently admitted patient and obtained a reading of 128/78 mm Hg. What is this patient's pulse pressure?

50 mm Hg

A nurse assesses the radial pulse of a client. Which pulse rate would the nurse document as bradycardia?

56 beats/minute

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

60-100 bpm

Due to a change in the client's level of consciousness, a nurse is now assessing a client's temperature by the axillary route. Previously, the client had an oral temperature of 98.4ºF. Which finding would the nurse interpret as corresponding most closely to the client's previous temperature?

97.4ºF

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 mmHg

What population is at greatest risk for hypertension?

African American

What are various measurements of the human body, including height and weight, called?

Anthropometric

A female client is admitted to the health care facility due to reports of decreased appetite, loss of sleep, feelings of being unsafe in her own home, and inability to concentrate. She appears pale; her hair is disheveled, she is not wearing makeup, and she will not make eye contact. Based on this data, which nursing diagnosis can the nurse confirm?

Anxiety

Before assessing vital signs, the nurse knows that it is important to assess what?

Any medications the client is currently taking

Which abnormal skin color should a nurse anticipate assessing on a dark-skinned client?

Ashen gray

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.

An 86-year-old male client 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 client 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 client's temperature by axilla

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

After assessing a client's radial pulse, the nurse determines that an apical pulse needs to be assessed. What will the nurse do when assessing the apical rate? (Select all that apply.)

Assess the rate for 1 minute. Place the stethoscope at the apex of the heart.

The nurse palpates a client's pulse and notes that the rate is 71 beats per minute, with an irregular rhythm. How should the nurse follow up this assessment finding?

Auscultate the client's apical pulse.

The nurse is auscultating a client's blood pressure and identifies the portion of the blood pressure cycle reflecting the break in sounds occurring between the first and second sounds. This is known as which of the following?

Auscultatory gap

The nurse is auscultating a client's blood pressure, and identifies which of the following as the portion of the blood pressure cycle reflecting the break in sounds occurring between the first and second sounds?

Auscultatory gap

The nurse is beginning examination of the client. All the following areas are important to observe as part of the general survey except:

Blood pressure

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?

Brachycardia

The nurse is admitting a client to surgical day care and is assessing the client's vital signs. When obtaining the client's oral temperature, where should the nurse insert the thermometer?

Deep in the posterior sublingual pocket

The nurse is conducting an assessment of an older adult client who has a diagnosis of chronic heart failure. How can the nurse best assess the effects of the client's stroke volume?

Calculate the difference between the diastolic and systolic pressures.

Which of the following would be most appropriate for the nurse to do to determine stroke volume?

Calculate the difference between the diastolic and systolic pressures.

What site of pulse assessment is used during an emergency assessment for an adult patient?

Cartoid pulse

Which technique demonstrates the proper position of the arm by a nurse when measuring a blood pressure?

Client sitting with arm outstretched and even with the heart

Which technique demonstrates the proper positioning of the client's arm by a nurse when measuring a blood pressure?

Client sitting with arm slightly flexed and even with the heart

The information gathered during a general survey provides the nurse primarily with which of the following?

Clues about the overall health of the client

What action is appropriate for a nurse to perform when an irregular radial pulse is palpated on a client?

Count the pulse for a full minute for an accurate rate

A nurse is assessing the general status and vital signs of a client. Which of the following are subjective findings, which the nurse obtained from the client? Select all that apply

Date and location of the clients last blood pressure check Onset and character of the clients chest pain A list of all of the client's current medications

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 is having trouble obtaining the pulse and BP in a patient who is in shock. What device would assist the nurse in obtaining the needed vital signs?

Doppler ultrasound

An elderly client is admitted with new onset of left sided weakness, slurred speech, and hypotension. The client's husband states that she has stopped taking her blood pressure medications for the past week because they were making her feel dizzy and lack of energy. Which nursing diagnosis can be confirmed from this data?

Dressing Self-Care Deficit

An elderly client is admitted with new onset of left-sided weakness, slurred speech, and hypotension. The client's husband states that she has stopped taking her blood pressure medications for the past week because they were making her feel dizzy and lacking in energy. Which nursing diagnosis can be confirmed from this data?

Dressing self-care deficit

A client comes in with shortness of breath and a productive cough. The client's body has black henna skin decorations in many areas including the fingertips. The nurse wants to assess the client's oxygen saturation. Where would the nurse most likely get an accurate reading of oxygen saturation?

Ear

When counting the patient's pulse, what beats may be difficult to detect peripherally?

Early beats

A nurse is preparing to assess an adult client's body temperature. At which time of the day would the nurse expect to obtain the lowest body temperature?

Early morning

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

Elongated fingers

The nurse is completing the general survey of a client and determines that the client's temperature is 102°F. Which of the following would the nurse also expect to find?

Heart rate greater than 100 bpm

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

Hypertension Vasoconstriction Peripheral vascular disease

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

Increased pulse rate

A nurse obtains a blood pressure on an elderly client of 160/70 mm Hg. The nurse knows that the term for this condition is what?

Isolated systolic hypertension

A nurse documents a client's radial pulse as 2+, indicated which of the following?

It occludes with moderate pressure.

Prior to inflating the cuff to measure the client's blood pressure, the nurse has palpated the radial artery, inflated the cuff, and noted the point at which the radial pulse disappears. What is the rationale for the nurse's action?

It prevents client discomfort and an auscultatory gap.

A nurse obtains the blood pressure in a client who is lying down. Which of the following would the nurse expect?

It will be slightly lower than standing readings.

When assessing an older adult client with osteoporotic thinning and vertebral collapse, which of the following findings would the nurse expect to identify?

Kyphosis

When assessing an older adult client with osteoporotic thinning and vertebral collapse, which of the following would the nurse expect to find?

Kyphosis

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

Level of consciousness

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

Neuropathic

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

Neuropathic

Two nurses collaborate in assessing an apical-radial pulse on a client. The pulse deficit is 16 beats/min. What does this indicate?

Not all of the heartbeats are reaching the periphery.

Two nurses collaborate in assessing an apical-radial pulse on a patient. The pulse deficit is 16 beats/min. What does this indicate?

Not all of the heartbeats are reaching the periphery.

An older client has an oral body temperature of 99.80F. Which action should the nurse take first?

Notify the health care provider

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.

During a busy shift, Nurse R. admitted a postsurgical patient who is obese. Nurse R. used the standard size of blood pressure cuff available on the unit, despite the fact that the patient'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.

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 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 client's thigh

The nurse places the following device on a client's finger. What information is this device providing to the nurse?

Oxygen saturation

When assessing a client's pulse, the nurse should be alert to which of the following characteristics?

Rate, rhythm, amplitude and contour, and elasticity.

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.

Since the nurse is unable to obtain an average-sized cuff to assess an adult patient with a large arm, the nurse uses an oversized cuff. What blood pressure reading will the nurse most likely obtain for this patient?

Reading will be high

Since the nurse is unable to obtain an oversized cuff to assess an adult client with a large arm, the nurse uses an average-sized cuff. What blood pressure reading will the nurse most likely obtain for this client?

Reading will be high

A nurse is taking a client's temperature and wants the most accurate measurement, based on core body temperature. What site should be used?

Rectal

A nurse is taking a patient's temperature and wants the most accurate measurement, based on core body temperature. What site should be used?

Rectal

The nurse is reviewing the following vital signs of a client who is lying in bed. Which of the following would the nurse identify as being abnormal?

Respirations 28 breaths/minute

Mrs. Helms is admitted to your unit with an exacerbation of COPD. When you enter her room to do your initial assessment, you note that she is sitting on the side of the bed, leaning forward, with her arms on the bedside table. What would this indicate to you?

Respiratory distress

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 client recovering from abdominal surgery is complaining of pain. The nurse realizes that the client is most likely experiencing which type of pain?

Somatic

A patient recovering from abdominal surgery is complaining of pain. The nurse realizes that the patient is most likely experiencing which type of pain?

Somatic

A client comes to the clinic for a follow-up evaluation of his blood pressure. On two previous visits his values were 140/88 mmHg and 144/92 mmHg. Today, the client's blood pressure is 146/94 mmHg. The nurse would categorize this client's blood pressure as which of the following?

Stage 1 hypertension

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

Stage 2 Hypertension

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

A client arrives in the emergency department in diabetic ketoacidosis. What assessment finding would the nurse expect in this client?

Sweet-smelling breath

A patient arrives in the emergency department in diabetic ketoacidosis. What assessment finding would the nurse expect in this patient?

Sweet-smelling breath

Various sounds are heard when assessing a blood pressure. What does the first sound heard through the stethoscope represent?

Systolic pressure

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

Tachycardia

A client's temperature is 102°F. Which of the following would the nurse also expect to find ?

Tachycardia greater than 100 bpm

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

Temperature

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

Temperature, pulse, respiration, and blood pressure

A nurse is preparing to assess a client's vital signs. In which order should the nurse assess them?

Temperature, pulse, respirations, and blood pressure

A nurse is assessing the blood pressure of a team of healthy athletes at the heath care facility. Which of the following observations can be made by the nurse and athletes by measuring the blood pressure?

The ability of the arteries to stretch

As adults age, the walls of their arterioles become less elastic, increasing resistance and decreasing compliance. How does this affect the blood pressure?

The blood pressure increases.

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.

A client has an oral temperature of 37.2 °C (99 °F). The nurse interviews the client. Which of the following pieces of interview data could be an influence on this high body temperature?

The client has just run 4.82 km (3 miles) outside before coming to the interview.

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.

A nurse is reviewing a colleague's documentation of a client assessment. The nurse reads that the client's radial pulse was 2+. How should the nurse interpret this assessment finding?

The client's radial pulse occluded with moderate pressure.

The nurse has begun a client's assessment and 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.

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.

The nurse is assessing a new patient's blood pressure using a manual sphygmomanometer. Which of the following sounds constitutes the patient's systolic blood pressure?

The first appearance of faint but distinctive tapping sounds

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 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 greater than 90 but less than 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

During a general survey, the nurse asks if the patient is feeling cold. What did the nurse most likely observe in the patient?

The patient is wearing clothing that is inconsistent with warm weather.

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

A young adult client comes to the ED reporting lower abdominal pain. Vital signs are BP 84/52, pulse 108, respirations 20, and temperature 99.2°F (37.3°C). The client's oxygen saturation is 98% on room air. She appears pale and states that the pain started several days ago but got much worse today. What is the purpose of getting an initial set of vital signs? Select all that apply.

To establish a baseline To determine if a specific body system needs more thorough investigation To gather information about trends over time

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

Students are touring the hospital before starting their clinical rotations. The instructor points out that the type of thermometer used in this facility is noninvasive, safe, efficient, and quick. What type of thermometer is the instructor describing?

Tympanic

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

Undiagnosed cardiovascular disease

The nurse understands that vital signs should be taken with what frequency? Select all that apply.

Upon admission to unit With a change in condition After surgery

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

An instructor is reviewing the steps to obtain a radial pulse. The instructor determines that the teaching was successful when the students demonstrate which of the following?

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

A client's blood pressure is affected by

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

An adolescent client presents to the health clinic for a routine physical examination. Which observation by the nurse needs validation by collection of objective data?

Wearing long sleeve clothing in July

The nurse is conducting a general survey of a client new to the clinic. In what part of the survey would the nurse assess the hair distribution on the client's body?

When assessing the skin

The nurse is conducting a general survey of a patient new to the clinic. In what part of the survey would the nurse assess the hair distribution on the patient's body?

When assessing the skin

The nurse begins a client assessment by conducting a general survey that focuses on objective observations. What is the primary purpose for collecting this sort of information first?

assists the nurse in formulating appropriate subjective questioning

A client's radial artery pulse rate is 42 beats in 30 seconds with occasional pauses. What action should the nurse take?

auscultate the heart rate for a full minute

A client is wearing a hospital gown and sitting on the examination table. What area should the nurse include when completing the general survey?

facial expression

Osteoporotic thinning and collapse of the vertebrae secondary to bone loss in an elderly client may result in

kyphosis

The nurse is preparing to assess an adult client in the clinic. The nurse observes that the client is wearing lightweight clothing that is worn and soiled, although the temperature is below freezing outside. The nurse anticipates that the client may be

lacking adequate finances.

A patient asks to have her temperature taken because she feels hot and is sweating. The previous oral temperature 3 hours ago was 101.6°F. The nurse would expect the new temperature reading to be

lower than previous

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.

The nurse is preparing to assess the respirations of an alert adult client. The nurse should

observe for equal bilateral chest expansion of 2.54 to 5.08 cm (1 to 2 in).

A client, sipping hot tea, is scheduled for routine vital signs. Which illustration shows the least appropriate method for the nurse to use to obtain an accurate temperature reading?

oral

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 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.

What information concerning a client's respirations should the nurse record after completing a general physical assessment?

rate, rhythm, and depth of respirations taken for a full minute

The nurse assesses the client's vital signs as follows: respirations 20 breaths/minute, tympanic temperature 100.9°F, pulse 88 beats/minute, and blood pressure 104/64 mm Hg. The nurse should

record the vital signs.

The nurse is going to take a blood pressure on a patient who has had a previous left mastectomy with lymph node dissection. What would be an appropriate action by the nurse?

take the blood pressure in the right arm