Chapter 25: Vital Signs

The nurse has completed an assessment and notes that the client's blood pressure is 132/92 mmHg. What is this client's pulse pressure?

40 mmHg The difference between systolic blood pressure and diastolic blood pressure is called the pulse pressure; 132 − 92 = 40.

The nurse discovers during assessment that the client has an altered temperature.

Radiation is heat that is lost to infrared heat waves. It can be accelerated by exposing the skin to the heat waves or prevented by covering the skin. Conduction describes heat that is lost by transfering from one object to the next. For example, heat is lost from the skin to the air or to water. Evaporation consists of heat loss that occurs as water is transformed into a gas, such as with sweating. Convection facilitates heat loss via passing air, such as with a breeze or a fan. Arterioveous shunts may remain open to facilitate the dissapation of heat from the body. A passing breeze facilitates heat loss via convection. In response to the body's temperature the sympathetic nervous system controls the opening and closing of arteriovenous shunts. Shivering is one mechanism for the body to retain heat. Heat can be lost through uncovered body surfaces by the physical process of radiation. Water in the form of a tepid bath or swimming is one way heat loss can occur through conduction. Insensible loss of body fluids is a form of evaporation that takes place on the skin. "Goose bumps" or piloerection is a natural response of the body to retain heat by reducting the surface area of the skin.

The home care nurse notices that the client only has a glass thermometer. What is the bestresponse by the nurse?

"Would you consider using a digital thermometer?" Assessing if the client is willing to use a digital thermometer is the most appropriate response, since these are safer and more accurate. Glass bulb thermometers usually contain mercury, which should not be disposed of in the garbage and is implied by "throw away". Cleaning should be done with a mixture of alcohol and water. and the thermometer should be rinsed with cold water only. The length of time that the client has owned the thermometer is not relevant to next steps.

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 attempts to count the respiratory rate of 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. Sometimes it is easier to count respirations by auscultating the lung sounds for 30 seconds and multiplying the result by 2. Palpating the posterior thorax excursion detects vibrations in the lungs. Pulse oximeter and arterial blood gas results assess respiratory effectiveness, not respiratory rate.

Which guideline should the nurse follow when assessing a client's blood pressure using a Doppler ultrasound?

Center the bladder of the cuff over the artery, lining up the artery marker on the cuff with the artery. When performing blood pressure assessment via Doppler ultrasound, the nurse will have the client assume a comfortable lying or sitting position with the appropriate limb exposed and center the bladder of the cuff over the artery, lining up the artery marker on the cuff with the artery. If using a mercury manometer, the nurse will check to see that the manometer is in the vertical position and that the mercury is within the zero level with the gauge at eye level. The nurse then hold the Doppler in the nondominant hand. Using the dominant hand, the nurse places the Doppler tip in the gel, adjusts the volume as needed, and moves the Doppler tip around until hearing the pulse.

A 78-year-old client is taking his own heart rate, as directed by his care provider and following the instructions provided by the nurse. The client's pulse is 56 beats per minute. What should he do next?

Document the finding This pulse falls within a normal range for an older adult male, which are often lower than younger adults. There is not enough information provided to assume anything other than a normal pulse rate for age; therefore, there is no need to retake it or call the health care provider. The risks of sudden postural changes are related to low blood pressure, not lower heart rate.

A nurse is assessing an adult client's blood pressure. How should the nurse estimate the client's systolic blood pressure (SBP)?

Inflate the blood pressure cuff while palpating the client's brachial or radial artery. The point where the brachial or radial pulse disappears provides an estimate of the systolic pressure. Previous baselines are important to know, but these do not provide an estimate of current SBP. Simultaneous palpation of radial pulses and having the client raise his or her arms does not provide an estimate of SBP.

The nurse identifies the auscultatory gap while taking the client's blood pressure. What should the nurse do next?

Inflate the cuff about 30 mm Hg above the auscultatory gap. To find the auscultatory gap, palpate the brachial or radial pulse while inflating the cuff. Inflate the cuff about 30 mm Hg above the number where palpable pulsation disappears. In addition to detecting an auscultatory gap, palpation gives an initial estimate of systolic blood pressure and eliminates the need to inflate the cuff to extremely high pressures in people with normal or low blood pressure. Using the bell of the stethoscope to listen for the systolic and diastolic sound is expected. Recording of the blood pressure should occur after the blood pressure is obtained.

The nurse is preparing to assess the peripheral pulse of an adult client. Which action is correct?

Lightly compress the client's radial artery using the first, second, and third fingers. The radial artery is the most common place to assess a peripheral pulse on an adult. The fingertips are sufficiently sensitive to palpate arterial pulsations using light compression and thus should be used, not the thumbs. The first, second, and third fingers of one hand are used to assess peripheral pulse, not the first fingers of each hand. Take care to avoid completely compressing the artery.

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

Rest 3 to 5 minutes before taking your BP. Take three 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 to 5 minutes before taking the measurement, ideally taking three measurements at one sitting and averaging them together. The client should be using a validated monitor with an automatic cuff. The client should be taught that the BP should be taken before eating, 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 client who 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. 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.

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 such as blankets. 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. Using a rectal thermometer or assuming the thermometer is broken is not correct. The client is not exhibiting signs of infection as these may include an elevated temperature, an elevated white blood cell count, general malaise, and body aches.

A nurse will assess the oral temperature of a postoperative client. Prior to performing this assessment, which should the nurse identify?

The client's most recent temperature Prior to assessment, the nurse should note the client's baseline or previous temperature measurements. Assessment results must always be considered in light of client-specific baselines. The client's wellness goals are important, but these are not directly relevant to temperature assessment. Similarly, nutritional status has a minimal bearing on temperature assessment. The client's preferred site for assessment is important, but the nurse ultimately determines the most appropriate site based on nursing knowledge.

A nurse is assessing a client's blood pressure manually. The nurse should identify the client's systolic blood pressure (SBP) when which event occurs?

The first faint, but clear, sound appears. The first faint, but clear, sound that appears and slowly increases in intensity constitutes the systolic pressure. Each of the other listed sounds would yield an inaccurate SBP reading.

The nurse is assessing the pulse of a young adult who is training for a triathlon competition. The pulse rate is 48 beats/min. What education should the nurse provide to the client?

The heart rate is within normal limits due to the exercise regimen the client is following. The client who is young and athletic is exhibiting a training effect where the heart rate is lower than the normal 60 to 100 beats/min. The heart becomes more efficient at supplying body cells with sufficient oxygenated blood with fewer beats. There is no indication that the client should be placed on medications to increase the heart rate since this is most likely a normal state for the client.

The nurse is assessing the blood pressure of a hospitalized client using a Doppler ultrasound device. Which actions are performed correctly? Select all that apply.

The nurse places the client in a comfortable lying or sitting position. The nurse centers the bladder of the cuff over the artery, lining the artery marker on the cuff up with the artery. The nurse wraps the cuff around the limb smoothly and snugly and fastens it. The nurse checks that the needle on the aneroid gauge is within the zero mark. Lying or sitting in a comfortable position allows for a more accurate measurement. Pressure in the cuff applied directly to the artery provides the most accurate readings. A smooth cuff and snug wrapping produce equal pressure and help promote an accurate measurement. A cuff wrapped too loosely results in an inaccurate reading. An aneroid gauge must be at zero when beginning to measure the blood pressure to help in ensuring accuracy. The manometer must be in the vertical position for BP measurement. Once the pulse is found with the Doppler the nurse should close the valve on the sphygmomanometer to allow for inflation of the BP cuff bladder.

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 mmHg. 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 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.

The nurse is preparing to measure a client's rectal temperature. Which supplies and equipment should the nurse have available before beginning the procedure? Select all that apply.

an electronic thermometer with a rectal probe disposable probe cover water-soluble lubricating gel Clean examination gloves, not sterile gloves, are required, and a bedpan is unnecessary. The other items listed are all needed.

Which is not a characteristic used to describe the pulse?

depth Rate or frequency refers to the number of pulsations per minute. Rhythm refers to the regularity with which pulsation occurs. Quality refers to the strength of the palpated pulsation.

The nurse is caring for a client who has smoked for more than 20 years and is now experiencing labored respirations. The nurse documents the client is experiencing:

dyspnea. Dyspnea describes respirations that require excessive effort, such as is common in clients who smoke, suffer from chronic obstructive pulmonary disease, or have been diagnosed with asthma. Stridor are harsh, loud, high-pitched sounds auscultated on inspiration that signal narrowing of the upper airway or presence of a foreign body in the airway. Wheeze is a continuous, high-pitched squeak or musical sound made as air moves through narrowed or partially obstructed airway passages. Fremitus vibration of the chest wall that can be palpated during the physical examination.

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.

A nursing student is assessing blood pressure in an adult client. Which action by the nursing student would require intervention from the nursing instructor?

pumping the blood pressure cuff up to 200 mm Hg routinely The instructor should intervene if the student is routinely inflating the cuff to 200 mm Hg. This may be very uncomfortable for the client, and there is no reason to do so unless the Korotkoff sounds are heard when inflating. All other options are correct and do not require intervention.

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

rectum The rectal temperature, a core temperature, is considered to be one of the most accurate routes.

A nurse is taking a blood pressure measurement to assess for orthostatic hypotension in a client. Which sign(s) and symptom(s) will the nurse assess related to this condition? Select all that apply.

report of feeling dizzy when sitting up from a supine position report of feeling palpitations when rising from a supine to a standing position report of feeling lightheaded when sitting up syncope Orthostatic hypotension occurs when the client's blood pressure decreases when moving from a sitting or lying position to a standing position. The systolic pressure drops by at least 20 mm Hg or the diastolic decreases by at least 10 mm Hg within 3 minutes of rising to the standing position. Common signs and symptoms of orthostatic hypotension include dizziness, lightheadedness, blurred vision, weakness, fatigue, nausea, palpitations, syncope and headaches.