Chapter 24, Vital Signs
A student is reading the medical record of an assigned client and notes the client has been afebrile for the past 12 hours. What does the term "afebrile" indicate? A) Normal body temperature B) Decreased body temperature C) Increased body temperature D) Fluctuating body temperature
Ans: A Feedback: A person with normal body temperature is referred to as afebrile.
The nurse notes a difference in systolic blood pressure readings between the client's arms. How will the nurse approach subsequent readings based upon this difference in blood pressures? A) The nurse will use the arm with the highest reading. B) The nurse will use the arm with the lowest reading. C) The nurse will average the two blood pressures and document this average. D) The nurse will obtain a blood pressure on the client's leg.
Ans: A Feedback: An initial nursing assessment should include blood pressure assessments on both arms. It is normal to have a 5- to 10- mm Hg difference in the systolic reading between arms. Use the arm with the higher reading for subsequent pressures.
A nurse needs to measure the pulse of a client admitted to the health care facility. Which site would the nurse most likely use? A) Femoral B) Temporal C) Pedal D) Radial
Ans: D Feedback: The radial artery is the site most commonly assessed in a clinical setting. The radial pulse is palpated on the thumb side of the inner aspect of the wrist. Deep palpation is required to detect the femoral pulse beneath the subcutaneous tissue, in the anterior medial aspect of the thigh, just below the inguinal ligament, about halfway between the anterior superior iliac spine and the symphysis pubis. The pulsation of the temporal artery is palpated in front of the upper part of the ear; however, it is not the site most commonly assessed in the clinical setting. The pedal pulse or dorsalis pedis pulse can be felt on the dorsal aspect of the foot; however, the dorsalis pedis pulse may be congenitally absent in some clients.
A hospital unit has a policy that rectal temperatures may not be taken on clients who have had cardiac surgery. What rationale supports this policy? A) It is an embarrassing and painful assessment. B) Thermometer insertion stimulates the vagus nerve. C) It is less expensive to take oral temperatures. D) It is to avoid perforating the wall of the rectum.
Ans: B Feedback: Because inserting the thermometer into the rectum can slow the heart rate by stimulating the vagus nerve, assessing a rectal temperature may not be allowed for clients after cardiac surgery.
Upon auscultation of a client's heart rate, the nurse notes the rate to have an irregular pattern of 72 beats/minute. The nurse notifies the physician because the client is exhibiting signs of which of the following? A) A dysrhythmia B) Tachycardia C) Bradycardia D) Hypertension
Ans: A Feedback: An irregular pattern of heartbeats is called a dysrhythmia. Tachycardia is an increased heart rate of 100 to 180 beats/minute. Bradycardia is a pulse rate below 60 beats/minute. The normal pulse rate ranges from 60 to 100 beats per minute. Hypertension is a blood pressure that is above normal for a sustained period.
When assessing a client's vital signs, a nursing student has explained each of her next actions prior to assessing the client's temperature, pulse, and blood pressure. However, the nurse has not announced her intention to assess the client's respiratory rate prior to measuring it. Which of the following is a plausible rationale for the nurse's decision? A) Respirations have both autonomic and voluntary control. B) The nurse likely assessed the client's respiratory rate simultaneous to heart rate. C) Temperature, pulse, and blood pressure are more volatile than respiratory rate. D) Tachypnea is an expected finding among hospitalized individuals.
Ans: A Feedback: Because respiratory rate is under both autonomic and voluntary control, making the client conscious of his or her respiratory rate prior to assessment has the potential to affect that accuracy of the assessment. It is not possible to simultaneously assess pulse and respirations. Temperature, pulse, and blood pressure are not necessarily more volatile than respiratory rate. Tachypnea is not an expected finding.
A nurse has an order to take the core temperature of a client. At which of the following sites would a core body temperature be measured? A) Rectal B) Oral C) Skin surface D) Axillary
Ans: A Feedback: Core temperatures are measured by nurses rectally. Surface body temperatures are measured at oral (sublingual), axillary, and skin surface sites.
A nurse is taking a client's temperature and wants the most accurate measurement, based on core body temperature. What site should be used? A) Rectal B) Oral C) Axillary D) Forehead
Ans: A Feedback: Heat is generated by metabolic processes in the core tissues of the body, transferred to the skin surface by the circulating blood, and then dissipated to the environment. Core body temperatures may be measured at rectal or tympanic sites.
A middle-aged, overweight adult man has had hypertension for 15 years. What pathologic event is he most at risk for? A) Stroke B) Anemia C) Cancer D) Infection
Ans: A Feedback: Hypertension is the most important risk factor associated with stroke.
A home health care nurse notices that his assigned client uses a mercury thermometer. He asks the nurse what to do if it breaks. Which of the following is not correct? A) "Just flush the glass and mercury down the toilet." B) "Do not vacuum the area where it breaks." C) "Open the windows and close off the room for an hour." D) "Throw away any clothing exposed to the mercury."
Ans: A Feedback: Mercury should never be flushed down the toilet. Mercury is not only hazardous to people but it also pollutes the environment, especially if it gets into water. The other responses are correct.
The nurse at the beginning of the shift plans to see which client first, based on the following vital signs? A) The client age 2 years whose respiratory rate is 16 breaths/minute B) The newborn whose axillary temperature is 98.2 ºF (36.8 ºC) C) The client age 7 years whose pulse is 120 beats/minute D) The client age 10 years whose blood pressure is 102/62 mmHg
Ans: A Feedback: Normal respiratory rate for a child 1 to 3 years of age is 20 to 40 breaths/minute. Therefore, the nurse should assess the 2-year-old with a respiratory rate of 16 first, as the other clients' vital signs are within normal limits.
A nurse is caring for a client who is ambulating for the first time after surgery. Upon standing, the client complains of dizziness and faintness. The client's blood pressure is 90/50. What is the name for this condition? A) Orthostatic hypotension B) Orthostatic hypertension C) Ambulatory bradycardia D) Ambulatory tachycardia
Ans: A Feedback: Orthostatic hypotension (postural hypotension) is a low blood pressure associated with weakness or fainting when one rises to an erect position (from supine to sitting, supine to standing, or sitting to standing). It is the result of peripheral vasodilation without a compensatory rise in cardiac output.
An male client 86 years of age 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. Additionally, he repeatedly withdraws his head when the nurse attempts to use a tympanic thermometer. How should the nurse proceed with this assessment? A) Assess the client's temperature by axilla. B) Assess the client's skin tone and the presence or absence of sweating to determine whether the client is febrile. C) Use a disposable mercury thermometer to take the client's temperature. D) Take the client's temperature rectally.
Ans: A Feedback: The axillary site is an accurate and acceptable alternative when other sites are impractical or contraindicated. Rectal temperatures are contraindicated in cardiac clients; mercury thermometers are not commonly used. It is unacceptable for the nurse to rely solely on subjective assessments to determine whether the client is febrile.
A nurse is assessing the blood pressure on an obese woman. What error might occur if the cuff used is too narrow? A) Reading is erroneously high B) Reading is erroneously low C) Pressure on the cuff with be painful D) It will be difficult to pump up the bladder
Ans: A Feedback: The bladder of the cuff should enclose at least two-thirds of the adult limb. If the cuff is too narrow, the reading could be erroneously high because the pressure is not being transmitted evenly to the artery.
Various sounds are heard when assessing a blood pressure. What does the first sound heard through the stethoscope represent? A) Systolic pressure B) Diastolic pressure C) Auscultatory gap D) Pulse pressure
Ans: A Feedback: The first sound heard through the stethoscope, which is the onset of phase I of Korotkoff sounds, represents the systolic pressure.
Which of the following is an average normal temperature in Centigrade for a healthy adult? A) oral: 37.0°C B) rectal: 36.5°C C) axillary: 37.5°C D) tympanic: 34.4°C
Ans: A Feedback: The normal range for an oral temperature is 37.0°C, a rectal temperature is 37.5°C, an axillary temperature is 36.5°C, and a tympanic temperature is 37.5°C.
A nurse palpates the pulse of a client and documents the following: 6/6/12 pulse 85 and regular, 3+, and equal in radial, popliteal, and dorsalis pedis. What does the number 3+ represent? A) Pulse rate B) Pulse quality (amplitude) C) Pulse rhythm D) Pulse deficit
Ans: B Feedback: Pulse quality/amplitude describes the quality of the pulse in terms of its fullness, ranging from absent (0) to bounding (4+). Pulse rates are measured in beats per minute. Pulse rhythm is the pattern of the pulsations and the pauses between them. The pulse deficit is the difference between the apical and radial pulse rates.
An adult client is assessed as having an apical pulse of 140. How would the nurse document this finding? A) Bradycardia B) Tachycardia C) Dysrhythmia D) Normal pulse
Ans: B Feedback: Tachycardia is a rapid pulse (heart) rate. An adult has tachycardia when the pulse rate is 100 to 180 beats/min. The nurse would document a rate of 140 as tachycardia. Bradycardia is a slower than normal pulse rate. Dysrhythmia is an irregular pulse rate.
Which is the primary source of heat in the body? A) Hormones B) Metabolism C) Blood circulation D) Muscles
Ans: B Feedback: The primary source of heat in the body is metabolism, with heat produced as a byproduct of metabolic activities that generate energy for cellular functions. Various mechanisms increase body metabolism, including hormones and exercise.
What anatomic site regulates the pulse rate and force? A) Thermoregulatory center B) Cardiac sinoatrial node C) Cardiac atria and valves D) Peripheral chemoreceptors
Ans: B Feedback: The pulse is regulated by the autonomic nervous system through the cardiac sinoatrial node. The other anatomic sites may affect, but do not regulate, the pulse rate and force.
A nurse is assessing a client who has a fever, has an infection of a flank incision, and is in severe pain. What type of pulse rate would be likely? A) Bradycardia B) Tachycardia C) Dysrhythmia D) Bigeminal
Ans: B Feedback: The pulse rate increases (tachycardia) and decreases in response to a variety of physiologic mechanisms. Tachycardia is a response to an elevated body temperature and pain.
Which of the following clients should the nurse monitor vital signs every four hours? A) A client in a critical care unit B) A client hospitalized for high blood pressure C) a resident in a long-term care facility D) a long-term care resident on Medicare A
Ans: B Feedback: Vital signs are assessed at least every four hours in hospitalized clients with elevated temperatures, with high or low blood pressures, with changes in pulse rate or rhythm, or with respiratory difficulty. In critical care settings, technologically advanced devices are used to continually monitor clients' vital signs. Regulations require monthly vital sign measurements in long-term care residents, but if the resident is classified as Medicare A (meaning discharged from the hospital and Medicare is paying for the stay to receive skilled nursing care) vital signs are taken daily.
The arterial blood gases for a client in shock demonstrate increased carbon dioxide and decreased oxygen. What type of respirations would the nurse expect to assess based on these findings? A) Absent and infrequent B) Shallow and slow C) Rapid and deep D) Noisy and difficult
Ans: C Feedback: Any condition causing an increase in carbon dioxide and a decrease in oxygen in the blood tends to increase the rate and depth of respirations. An increase in carbon dioxide is the most powerful respiratory stimulant.
What site for taking body temperature with a glass thermometer is contraindicated in clients who are unconscious? A) Rectal B) Tympanic C) Oral D) Axillary
Ans: C Feedback: Assessing an oral temperature with a glass thermometer is contraindicated in unconscious, irrational, or seizure-prone adults, as well as in infants and young children. This is due to the danger of breaking the thermometer in the mouth.
A nurse is caring for a middle-aged client who looks worried and flares his nostrils when breathing. The client complains of difficulty in breathing, even when he walks to the bathroom. Which of the following breathing disorders is most appropriate to describe the client's condition? A) Hyperventilation B) Hypoventilation C) Dyspnea D) Apnea
Ans: C Feedback: Clients with dyspnea usually appear anxious and worried. The nostrils flare as they fight to fill the lungs with air. Dyspnea is almost always accompanied by a rapid respiratory rate because clients work to improve the efficiency of their breathing. The client's condition cannot be termed hyperventilation, hypoventilation, or apnea. Hyperventilation and hypoventilation affect the volume of air entering and leaving the lungs. Apnea is total absence of breathing, which is life-threatening if it lasts more than four to six minutes.
A client is constipated and trying to have a bowel movement. How does holding the breath and pushing down (the Valsalva maneuver) affect the pulse? A) Left ventricle pumps more forcefully; pulse is stronger B) Stimulates the vagus nerve to increase the rate C) Stimulates the vagus nerve to decrease the rate D) Right ventricle is less efficient; pulse is thready
Ans: C Feedback: Parasympathetic stimulation via the vagus nerve decreases the heart rate. The Valsalva maneuver stimulates the vagus nerve, resulting in a slower pulse rate.
A nurse is conducting a health history for a client with a chronic respiratory problem. What question might the nurse ask to assess for orthopnea? A) "Do you have problems breathing when you walk up stairs?" B) "Does your medication help you breathe better?" C) "How many pillows do you sleep on at night to breathe better?" D) "Tell me about your breathing difficulties since you stopped smoking."
Ans: C Feedback: People with difficulty breathing can often breathe more easily in an upright position, a condition known as orthopnea. While sitting or standing, gravity lowers organs in the abdominal cavity away from the diaphragm, giving more room for the lungs to expand. People with orthopnea characteristically use many pillows during sleep to accomplish this.
A client in a physician's office has a single blood pressure (BP) reading of 150/92. Should the client be taught about hypertension? A) It depends on the time of day the BP was taken. B) It depends on whether the client is male or female. C) No, a single BP reading should not be used. D) Yes, this reading is high enough to be significant.
Ans: C Feedback: The American Heart Association recommends that blood pressure readings be averaged on two or more subsequent occasions before diagnosing hypertension.
Two nurses collaborate in assessing an apical-radial pulse on a client. The pulse deficit is 16 beats/minute. What does this indicate? A) The radial pulse is more rapid than the apical pulse. B) This is a normal finding and should be ignored. C) The client's arteries are very compliant. D) Not all of the heartbeats are reaching the periphery.
Ans: D Feedback: A difference between the apical and radial pulse rates is the pulse deficit, and signals that all of the heartbeats are not reaching the peripheral arteries or are too weak to be palpated.
All of the following clients have a body temperature of 38°C (100.4°F). About which client would a nurse be most concerned? A) An older adult B) A pregnant adolescent C) A junior high football player D) An infant 2 months of age
Ans: D Feedback: A mild elevation in body temperature, as is given here, might indicate a serious infection in infants younger than 3 months of age, who do not have well-developed temperature control mechanisms.
A nurse places a fan in the room of a client who is overheated. This is an example of heat loss related to which of the following mechanisms of heat transfer? A) Evaporation B) Radiation C) Conduction D) Convection
Ans: D Feedback: Convection is the dissemination of heat by motion between areas of unequal density, as occurs with a fan blowing over a warm body. Evaporation is the conversion of a liquid to a vapor. Radiation is the diffusion or dissemination of heat by electromagnetic waves. Conduction is the transfer of heat to another object during direct contact.
A nurse educator is teaching a client about a healthy diet. What information would be included to reduce the risk of hypertension? A) "Eat a diet high in fruits and vegetables." B) "Remember to drink eight to 10 glasses of water a day." C) "It is important to have increased fats in your diet." D) "Put away the salt shaker and eat low-salt foods."
Ans: D Feedback: High salt intake is a high risk factor for the development of hypertension.
What population is at greatest risk for hypertension? A) Hispanic B) White C) Asian D) African American
Ans: D Feedback: Race is a factor in hypertension, a disorder characterized by high blood pressure. It is more prevalent and more severe in African American men and women.
As adults age, the walls of their arterioles become less elastic, increasing resistance and decreasing compliance. How does this affect the blood pressure? A) The blood pressure does not change. B) The blood pressure is erratic. C) The blood pressure decreases. D) The blood pressure increases.
Ans: D Feedback: The elasticity and resistance of the walls of the arterioles help to maintain normal blood pressure. With aging, the walls of arterioles become less elastic, which interferes with their ability to stretch and dilate, contributing to a rising pressure within the vascular system. This is reflected in an increased blood pressure.
A nurse walks into a client's room and finds him having difficulty breathing and complaining of chest pain. He has bradycardia and hypotension. What should the nurse do next? A) Take vital signs again in 15 to 30 minutes. B) Document the data and report it later. C) Ask the client if he is anxious or afraid. D) Report findings to the physician immediately.
Ans: D Feedback: The nurse should immediately report bradycardia associated with difficult breathing, changes in level of consciousness, hypotension, ECG changes, and angina (chest pain). Emergency treatment is by administering atropine intravenously to block vagal stimulation and restore normal heart rate.