Chapter 25: Vital Signs PrepU

The home care nurse notices that the client only has a glass thermometer. What is the best response by the nurse? -"Why are you using this thermometer?" -"Let's clean this off with hot water before use." -"Would you consider using a digital thermometer?" -"You need to throw that away; it is dangerous."

"Would you consider using a digital thermometer?" Assessing if the client is willing to use a digital thermometer is the most appropriate response. Telling the client to throw away their property is disrespectful and presumptuous. Cleaning should be done with a mixture of alcohol and water. and the thermometer should be rinsed with cold water only.

When assessing an infant's axillary temperature, it will be: -the same as the tympanic temperature. -1°F (0.5°C) higher than an oral temperature. -1°F (0.5°C) higher than a rectal temperature. -1°F (0.5°C) lower than an oral temperature.

1°F (0.5°C) lower than an oral temperature. Rectal temperatures may be 1°F (0.5°C) higher than oral temperatures and axillary temperatures are 1°F (0.5°C) lower than oral temperatures.

A nurse is assessing the respiratory rate of a sleeping 28-day-old infant. What would the nurse document as a normal finding? -12 to 20 breaths/min -30 to 60 breaths/min -60 to 80 breaths/min -80 to 100 breaths/min

30 to 60 breaths/min When assessing the respiratory rate of an infant less than 1 month of age, the nurse knows that the normal respiratory rate of an infant at rest is approximately 30 to 60 breaths/min. The normal respiratory rate of an adult is 12 to 20 breaths/min. A respiratory rate of 60 to 80 breaths/min or 80 to 100 breaths/min is abnormal and is not seen in infants or adults when they are at rest.

The nurse is attempting to assess a client's radial pulse. The pulse is weak, irregular and unable to be counted. What action would the nurse take next? -Document the findings. -Assess the apical pulse. -Assess the carotid pulse. -Get another nurse for validation.

Assess the apical pulse. If a radial pulse is difficult to assess accurately because it is irregular, feeble, or extremely rapid, the nurse would need to assess the apical pulse rate. By assessing the apical rate the nurse can hear the rate instead of trying to feel the rate. Assessing the carotid pulse would also be done through touch, so the outcome would be the same and not accurate. If the nurse is concerned about the client, it does not hurt to have another nurse check the pulse, but the nurse should assess the apical pulse first. The findings should be documented, but only after all assessments have been completed.

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. -Simultaneously compare the amplitude of the client's left and right radial pulses. -Note the SBP that was documented during the client's last vital signs assessment. -Palpate the client's brachial pulse while having the client slowly raise his or her arm.

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.

A nurse is explaining to a nursing student why blood pressure is a frequently used assessment parameter in a wide variety of care settings. What can be inferred from an assessment of a client's blood pressure? -The amount of oxygen available to tissues throughout the body -The resistance that the client's heart must overcome when pumping blood -The size of the client's heart muscle -The volume of the venous system relative to the volume of the arterial system

The resistance that the client's heart must overcome when pumping blood Blood pressure is representative of the amount of resistance that the heart must overcome in order to pump blood; increased BP equates with increased resistance, or afterload. Blood pressure is not necessarily indicative of oxygen supply, the relative volumes of the venous and arterial systems or the size of the heart.

The nurse is taking the apical pulse of a 6-month-old infant. Upon completion, the nurse tells the parent the baby's pulse is 140 beats per minute. The parent is concerned, stating, "That seems kind of high!" The nurse responds: "Yes, this is termed tachypnea. I will let the doctor know right away." "Yes, it seems fast but actually, normal infant heart rates are 150-200 beats per minute so it is a bit slow." "I know it seems fast, but normal infant heart rates are 100-160 beats per minute." "Yes, this is termed tachycardia. I will let the doctor know right away."

"I know it seems fast, but normal infant heart rates are 100-160 beats per minute." The average pulse rate of an infant ranges from 100 to 160 beats per minute.

The registered nurse is collaborating in the care of several medical clients. Which tasks may the nurse safely delegate to unlicensed assistive personnel (UAP)? Select all that apply. -Assessment of a client's axillary temperature -Assessment of a client's radial pulse -Assessment of body temperature for an infant in a radiant warmer -Palpation of a stable client's apical pulse -Auscultation of a client's apical heart rate

-Assessment of a client's axillary temperature -Assessment of a client's radial pulse Assessment of axillary temperature and radial pulse can normally be delegated to UAP. Assessment of apical heart rate and assessment of body temperature for an infant in a radiant warmer are beyond the scope of UAP.

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. -Note the assessment site used because axillary temperatures are generally about 1°F (0.5°C) more than oral temperatures and rectal temperatures are generally about 1°F (0.5°C) less than oral temperatures. -When assessing axillary temperature using a glass thermometer, place the bulb at the edge of the axilla and bring the client's arm down close to the body. Leave the thermometer in place for 3 minutes. -When assessing tympanic membrane temperature, wipe the tympanic probe cover with alcohol before inserting it snugly into the ear. -When assessing an oral temperature with an electronic thermometer, place the probe beneath the client's tongue in the posterior sublingual pocket. -When assessing temperature with an electronic thermometer, hold the thermometer in place in the assessment site until a beep is heard. -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 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.

A client has an axillary temperature of 102.6 F (39.2°C). Which clinical manifestations would the nurse anticipate? Select all that apply. -headache -red or flushed skin -hunger -cold, clammy skin -respiratory rate 30/min

-respiratory rate 30/min -headache -red or flushed skin The following are clinical signs associated with a fever: pinkish or red skin (skin that is warm to the touch), headache, and above-normal pulse or respiratory rates. Clients who are febrile may or may not be hungry. Clients who are febrile have warm, not cold and clammy, skin.

The nurse has requested the unlicensed assistive personnel (UAP) check the temperature of a 19-month-old client who has been admitted for pneumonia. Which reading should the nurse question if noted in the record? -101.2°F/38.4°C (O) -100.8°F/38.2°C (R) -99.9°F/37.7°C (AX) -102.4°F/39.1°C (T)

102.4°F/39.1°C (T) There are several ways to assess the temperature of a client: oral (O), rectal (R), axillary (AX), tympanic (T), and temporal artery (TA). The nurse should question the use of the tympanic thermometer. It is contraindicated for children younger than 2 years due to the smaller size of the ear canal. It is too small for the probe and an accurate reading cannot be obtained. In normal healthy adults the shell temperature generally ranges from 96.6°F to 99.3°F (35.8°C to 37.4°C); core body temperatures ranges from 97.0°F to 99.5°F (36.0°C to 37.5°C). Rectal and arterial temperatures are generally 1°F (0.5°C) higher than oral and 2°F (1°C) higher than axillary. The baseline temperatures for each method are: oral 98.5°F (37.0°C), rectal 99.5°F (37.5°C), axillary 97.5°F (36.4°C), tympanic 99.5°F (37.4°C), and temporal artery 99.4°F (37.4°C). Each of these temperatures would need to be assessed further for the possibility of a fever; however, the one assessed via the tympanic membrane would need to be assessed for accuracy and ensure the UAP does not need further training.

Based upon circadian rhythms, when would the nurse note the highest temperature during a 24-hour period? -1100 -1700 -0300 -1500

1700 Body temperature fluctuates throughout the day. Temperature is usually lowest around 0300 and highest from 1700 to1900.

The nurse has palpated the client's radial artery and identified a heart rate of 88 beats per minute with an irregular rate. What is the nurse's most appropriate action? -Auscultate the client's apical heart rate. -Page the client's primary care provider. -Reassess the client's radial pulse in 15 minutes. -Palpate the radial pulse on the opposite wrist.

Auscultate the client's apical heart rate. Palpation of an irregular radial pulse should be followed by assessment of the apical pulse in order to confirm the finding. Informing the health care provider is generally necessary only when this is a new finding.

Which guideline should the nurse follow when assessing a client's blood pressure using a Doppler ultrasound? -If using a mercury manometer, check to see that the manometer is in the horizontal position and that the mercury is within the zero level. -Take the measurement with the client in a standing position with the appropriate limb exposed. -Monitor for serial readings and check the cuffed limb frequently for inadequate arterial perfusion and venous drainage. -Center the bladder of the cuff over the artery, lining up the artery marker on the cuff with the artery.

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.

The nurse is assessing the client's blood pressure (BP) and heart rate (HR) for orthostatic hypotension. In which step should this nurse intervene because of potential danger? -After 3 minutes of sitting, BP 100/50; HR 90. -Client sitting at edge of bed, feet dangling for 3 minutes; asymptomatic -Client stands at bedside, becomes pale, diaphoretic. -Client in supine position for 3 minutes and BP 120/70; HR 70; asymptomati

Client stands at bedside, becomes pale, diaphoretic. Orthostatic hypotension is assessed in three positions, with the client resting in each position 3 minutes before measuring the blood pressure and heart rate. The client is positive for orthostatic hypotension when there is a decrease of 20 mm Hg BP or greater and the heart rate increases as the body's means to help compensate for the postural change. In this case, it is part of the assessment to leave the client in the supine position for 3 minutes; the BP and HR are within a normal range and the client is asymptomatic so the nurse would not intervene. The nurse need not intervene while the client is dangling at the bedside and is asymptomatic. After 3 minutes of sitting, there was a positive orthostatic change, but the client is not exhibiting symptoms, so the nurse would finish the assessment by standing the client at the bedside to determine the extent of the postural changes. The nurse would intervene because the client is exhibiting symptoms of low cardiac output: pallor and diaphoresis. The nurse would immediately place the client in a supine position to increase the BP and report the findings to the primary care provider so adjustments in treatment may be made.

When assessing a client's respiratory rate, the nurse should take which action? -Ask the client to breathe deeply. -Count the number of respirations for 10 seconds. -Do it immediately after the pulse assessment so the client is unaware of it. -Remind the client to breathe normally.

Do it immediately after the pulse assessment so the client is unaware of it. Move immediately from the pulse assessment to counting the respiratory rate to avoid letting the client know the nurse is counting respirations. Clients should be unaware of the respiratory assessment because, if they are conscious of the procedure, they might alter their breathing patterns or rate. Thus, the nurse should not tell the client to breathe normally or deeply. Using a watch with a second hand, count the number of respirations for 30 seconds. Multiply this number by 2 to calculate the respiratory rate per minute.

A nursing student is manually taking the client's blood pressure. Which step will demonstrate the correct way of inflating the blood pressure cuff? -Place cuff 8 cm above the elbow. -Fully inflate cuff for about 1 minute. -Inflate the cuff to 30 mm Hg above reading where brachial pulse disappeared. -Elevate arm above heart level before inflating the cuff.

Inflate the cuff to 30 mm Hg above reading where brachial pulse disappeared. Inflating the cuff to 30 mm Hg above reading where brachial pulse disappeared ensures accurate assessment of systolic blood pressure. The arm does not need to be elevated above the heart level before inflation as this would give an inaccurate systolic blood pressure. The cuff should be placed in the elbow fold and not 8 cm above the elbow. Inflating the cuff for 1 minute before taking a blood pressure can cause an elevation of the systolic blood pressure.

A nurse needs to measure the blood pressure of a client with an electronic manometer. Which of the following advantages does an electronic manometer provide over an aneroid manometer or mercury manometer? -Ability to read gauge from any direction. -Need for readjustment is eliminated. -No stethoscope is required. -Inexpensive depending on quality.

No stethoscope is required. An electronic manometer eliminates the need for a stethoscope. However, an electronic manometer requires a calibration check and readjustment every 6 months, unlike a mercury manometer which does not require readjustment. An electronic manometer is expensive depending on quality when compared to an aneroid manometer. A nurse can read the gauge of an aneroid manometer, not an electronic manometer, from any direction.

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? -Brachial artery -Over the lower arm -Radial artery -Over the client's thigh

Over the client's thigh The nurse should measure the blood pressure over the client's thigh or the popliteal artery behind the knee. It is inadvisable following a mastectomy to assess blood pressure at the normal site, which is over the brachial artery at the inner aspect of the elbow. In normal cases, the blood pressure may also be assessed at the lower arm and radial artery.

A nurse is assessing the pulse volume of a client with influenza. The nurse notes that the client has a thready pulse. Which of the following is a description of a thready pulse? -Pulse is felt with difficulty and disappears with slight pressure. -Pulse is felt easily, and moderate pressure causes it to disappear. -Pulse is strong and remains strong despite moderate pressure. -Pulse is strong, and light pressure causes it to disappear.

Pulse is felt with difficulty and disappears with slight pressure. A thready pulse is felt with difficulty or not easily felt, and slight pressure causes it to disappear. A weak pulse is stronger than a thready pulse, and light pressure causes it to disappear. A normal pulse is felt easily, and moderate pressure causes it to disappear. A bounding pulse is strong and does not disappear with moderate pressure.

The nurse is taking a rectal temperature on a client who reports feeling lightheaded during the procedure. What would be the nurse's priority action in this situation? Remove the thermometer and assess the blood pressure and heart rate. Call for assistance and anticipate the need for CPR. Remove the thermometer and assess the temperature via another method. Leave the thermometer in and notify the physician.

Remove the thermometer and assess the blood pressure and heart rate. Vagal nerve stimulation may occur when obtaining a rectal temperature. Vagal nerve stimulation can cause the pulse and blood pressure to drop significantly, causing the client to feel lightheaded; therefore, the thermometer should be removed immediately and the pulse and blood pressure assessed. The physician can be called after assessing the client. The temperature is not the priority at this time. Assistance for CPR would be determined if the client's condition worsens.

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 thermometer is broken. -A rectal thermometer must be used. -The client is showing initial signs of infection. -The client is covered with a couple of thick blankets.

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.

The nurse teaches a client diagnosed with hypertension to self-measure blood pressure with an automated device. Which client behavior indicates the need for additional teaching? -The client places the blood pressure cup on the upper arm just above the antecubital space. -The client sits in the chair with feet flat on the floor and arm supported at the level of the heart. -The client sits in the chair with feet flat on the floor and arm below the level of the heart. -The client uses a blood pressure cuff width at least 40% of the circumference of the midpoint of the arm.

The client sits in the chair with feet flat on the floor and arm below the level of the heart. The client behavior that indicates the need for additional teaching is client sitting in the chair with feet flat on the floor and arm below the level of the heart. Taking a blood pressure with the arm in that position can give a falsely high reading. The client placing the blood pressure on the upper arm just above the antecubital space, the client sitting in the chair with feet flat on the floor and arm supported at the level of the heart, and the client using a blood pressure cuff width at least 40% of the circumference of the midpoint of the arm all indicated correct methodology for self-measuring blood pressure and thus require no need for further teaching.

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 audible sounds begin to decrease in intensity. -The initial Korotkoff sounds peak in intensity. -The first audible sounds cease to be distinct. -The first faint, but clear, sound appears.

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.

Which client's blood pressure best describes the condition called hypotension? -The systolic reading is above 110 and diastolic reading is above 80. -The systolic reading is below 120 and the diastolic reading is below 80. -The systolic reading is below 100 and diastolic reading is below 60. -The systolic reading is above 102 and diastolic reading is above 60.

The systolic reading is below 100 and diastolic reading is below 60. Hypotension is defined by a systolic pressure below 100 mm Hg and diastolic pressure less than 60 mm Hg. The top number refers to the amount of pressure in the arteries during the contraction of heart muscle. This is called systolic pressure. The bottom number refers to the blood pressure when the heart muscle is between beats. This is called diastolic pressure. Ideal blood pressure is less than 140/90.

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. -There is a nonauscultatory gap. -There is a widening in the diameter of the artery. -There is an adult diastolic pressure.

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 62-year-old female client being treated for hypertension did not take her daily BP medication over the weekend because she was out of medication and the pharmacy was closed. Her average home blood pressure monitoring (HBPM) reading has been 130/82. Today her BP has been 138/90, 135/85, and 142/86. She calls the on-call nurse for her health care provider. What is the most appropriate thing for this nurse to advise this client? -Not to worry and to take double the dose of BP medication -To take the recommended daily dose of medication and call the health care provider if the average of her HBPM readings increase/decrease by 10, or if she has any other concerns. -To call her health care provider -To take the medication that she missed and retake her BP

To take the recommended daily dose of medication and call the health care provider if the average of her HBPM readings increase/decrease by 10, or if she has any other concerns. HBPM readings are the ideal method for monitoring response to treatment for high BP. This client's average BP after not taking her medication is 138/87 and is not 10 more than what her HBPM reading has been. Clients should be taught when performing HBPM that they should call the health care provider if the averages of HBPM readings increase/decrease by 10, or if she has any concerns. The client should not be told to take double the dose of medication or to take the doses she missed; this is unsafe advice without consulting a health care provider.

The student nurse is having difficulty feeling the pedal pulse of the client with a fractured leg. What should the nurse do next? -Ask another student nurse to check it for him. -Connect the client to the oxygen saturation monitoring device. -Use the Doppler ultrasound device. -Use the Bell side of the stethoscope to listen.

Use the Doppler ultrasound device. Peripheral pulses that cannot be detected by palpation may be assessed with an ultrasonic Doppler device. A conductive gel is first applied to the skin to reduce resistance to sound transmission. The transmitter of the device is then placed over the artery to be assessed. High-frequency waves directed at the artery from the transmitter are disturbed by the pulsating flow of blood and are reflected back to the ultrasound device. The sound disturbances (Doppler shifts) are amplified and heard through earpieces or a speaker attached to the device. The bell effect is created by light pressure on the stethoscope. Using the bell will not facilitate palpation but an auditory assessment. The nursing student should be familiar with other assessment devices such as the Doppler and not asking another nursing student to assess. Connecting the client to the oxygen saturation device does not assist in the assessment of pedal pulses.

A nurse plans to measure the temperature of a client with mild diarrhea, but the client has just had hot soup. Which action should the nurse perform to obtain the accurate temperature of the client? -Use the axillary site for an alternate measurement site -Ask the client to drink a glass of cold water before measuring the oral temperature -Wait for 30 minutes before measuring the oral temperature -Obtain the client's temperature rectally after lubricating the rectum

Wait for 30 minutes before measuring the oral temperature The nurse should wait for 15 to 30 minutes and then measure the oral temperature of the client since hot and cold liquids cause slight variations in temperature. Giving the client a glassful of cold water to drink will not help because the thermometer will still show temperature variation, not the accurate body temperature. The rectal route is contraindicated in clients with diarrhea, because it can cause mucosal tearing or perforation. Hence, the nurse should not lubricate the client's rectum or measure the rectal temperature. The axillary route is the least accurate and least reliable site.

A 70-year-old client is taking his own pulse at home. He is following the instructions provided by the nurse. He counts his pulse 62 times in one minute. What should he do next? -Write it down -Call the health care provider because it is too high for his age -Call the health care provider because it is too low for his age -Take it again over 30 seconds

Write it down This pulse falls within a normal range for an older adult male, 40 to 100 beats per minute. He should document his pulse rate. 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.

Which client would the nurse consider at risk for low blood pressure? -a client with low blood volume -a client with a strong pumping action of blood into the arteries -a client with high blood viscosity -a client with decreased elasticity of walls of arterioles

a client with low blood volume Low blood volume, such as occurs with hemorrhage, causes hypotension. High blood viscosity and decreased elasticity of the arteriole walls would potentially cause increased blood pressure. A strong pumping action of the heart may not affect the blood pressure, or it may cause the blood pressure to increase.

An 80-year-old client has a body temperature of 97°F (36°C). Which condition best accounts for this client's temperature reading? -hypothyroidism -advanced age -altered endocrine -function anemia

advanced age It is common for older adults to have body temperatures less than 97°F (36°C), because normal temperature drops as a person ages.

An obese client has developed peripheral edema as a consequence of heart failure, making it very difficult for the student nurse to accurately palpate the client's peripheral pulses. How should the nurse proceed with this assessment? -auscultate the client's brachial artery -arrange for cardiac monitoring -palpate the client's apical pulse -auscultate the client's apical pulse

auscultate the client's apical pulse When peripheral pulses are difficult to palpate, it is appropriate to auscultate the apex. This is preferable to auscultating a peripheral site, such as the brachial artery, and more accurate than attempting to palpate the apical pulse. Cardiac monitoring is not necessarily indicated in this case.

The nurse is preparing to assess a client's oral temperature. The nurse should plan to place the thermometer probe in which area of the client's mouth? -deep in the posterior sublingual pocket -superior to the tongue, with the tip touching the hard palate -along either upper gum line, adjacent to an incisor -in the inferior buccal space on either side of the tongue

deep in the posterior sublingual pocket When the probe rests deep in the posterior sublingual pocket, it is in contact with blood vessels lying close to the surface. None of the other areas provides as much contact with blood vessels and therefore is not an appropriate location to place the thermometer probe.

The temperature is 102°F (39°C) during a heat wave. The nurse can expect admissions to the emergency room to present with: -increased temperature. -decreased heart rate. -decreased respirations. -increased cardiac output.

increased temperature. Body temperature can fluctuate with exercise, changes in hormone levels, changes in metabolic rate, and extremes of external temperature.

A nurse is filling out an incident report after an older adult client fell while attempting to transfer from her bed to a commode. Which health problem should the nurse consider when client falls occur? -secondary hypertension -primary hypertension -orthostatic hypotension -dyspnea

orthostatic hypotension Orthostatic hypotension is associated with weakness or fainting when one rises to an erect position. Hypertension and dyspnea do not typically result in loss of balance and/or consciousness. Dyspnea is difficult or labored breathing. Essential or primary hypertension is high blood pressure. Secondary hypertension (secondary high blood pressure) is high blood pressure that's caused by another medical condition.

Which term indicates a potentially serious client condition? -pyrexia -pulse pressure -afebrile -eupnea

pyrexia Pyrexia means an increase above normal in body temperature. Pulse pressure is an objective term related to the pulse. Eupnea means a normal breathing pattern. Afebrile means that the body temperature is not elevated.

A nurse is assessing the blood pressure of a team of healthy athletes at the heath care facility. Which observation can be made by the nurse and athletes by measuring the blood pressure? -the oxygen levels in the blood -the ability of the arteries to stretch -the thickness of circulating blood -the volume of air entering the lungs

the ability of the arteries to stretch Measuring the blood pressure helps to assess the efficiency of the client's circulatory system. Blood pressure measurements reflect the ability of the arteries to stretch, the volume of circulating blood, and the amount of resistance the heart must overcome when it pumps blood. Measuring the blood pressure does not help in assessing the thickness of blood, oxygen level in the blood, or the volume of air entering the lungs.