chapter 8

Blood pressure cuff is tightly fitted.

A 55-year-old bookkeeper comes to the office for a routine visit. The nurse notes that on a previous visit for treatment of contact dermatitis, the client's blood pressure was elevated. She does not have prior elevated readings, and her family history is negative for hypertension. The nurse measures her blood pressure in the office today. Which of the following factors can result in a false high reading?

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 >90 but

facial expression

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

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

A client's blood pressure is affected by

Depression

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?

Anxiety

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?

30 to 50 mm Hg.

A normal pulse pressure range for an adult client is typically

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

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.

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 140/75 mm Hg. Which blood pressure reading with the client standing should the nurse recognize as orthostatic hypotension?

120/55 mmHg

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?

Pulse is felt with difficulty and disappears with slight pressure.

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?

"Do you need to empty your bladder?"

A nurse measures a client's blood pressure and obtains a reading of 150/85 mmHg. Which question should the nurse ask the client in regards to this reading?

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 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?

Alcoholism

A nurse notes that a client looks much older than his chronologic age. Which of the following conditions would most likely contribute to this appearance?

Marfan's syndrome

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?

Higher than normal

An older adult client with COPD has come to the clinic for a routine follow-up visit. The nurse escorts the client to an examination room and measures vital signs. The nurse would expect the patient's vital signs to be what?

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

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?

Chronic pulmonary obstructive disease

During the physical assessment of a client, a nurse observes that the client tends to lean forward and brace himself with his arms. The nurse recognizes this as a sign of what disease process?

Developing nursing diagnoses

How does the nurse use critical thinking when accurately assessing vital signs?

Palpitation

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?

kyphosis

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

Increased heart rate Increased blood pressure Increased cardiac output

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

orthostatic hypotension

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

Normal readings vary according to age

The nurse aide reports to the nurse that an older adult client has abnormal vital signs. What is important to remember in this type of situation?

1+

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?

record the vital signs.

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

Hypertension Vasoconstriction Peripheral vascular disease

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

Notify the rapid response team

The nurse is admitting an elderly client with a diagnosis of congestive heart failure. Admission vital signs are respirations 38; pulse 172; blood pressure 86/72. How should the nurse best respond?

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

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

The first appearance of faint but distinctive tapping sounds

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?

Rigid

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?

vital signs.

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

Blood pressure

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

State of health

The nurse is caring for a newly admitted adult client. When performing the general survey of this client, the nurse knows that accurate measurements provide critical information about what?

Document the finding

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?

Elongated fingers

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?

Retake the blood pressure

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?

Cyanotic left lower extremity

The nurse should immediately notify the healthcare provider if which assessment finding is obtained on a hospitalized client?

Elevated due to pain Elevated due to anxiety Elevated due to activity

The paramedics are called to a gym to see an individual who has been exercising and developed pain in the upper right quadrant of the abdomen. The initial vital sign reading indicates a pulse of 175 beats per minute. This pulse would be considered what? (Mark all that apply.)

Systolic pressure 180 mm Hg.

Upon entering an adult client's room to begin a shift assessment, the nurse should call the rapid response team based on which assessment finding?

Systolic pressure

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

Count the pulse for a full minute for an accurate rate

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

Ethnicity of patient Nutrition Genetic composition Geographic location Cultural norms

What factors contribute to the patient's individual makeup? (Select all that apply.)

Rate, rhythm, amplitude and contour, and elasticity.

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

Presence of dyspnea

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

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?

There is an auscultatory gap

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?

Arm

A nurse is assessing the blood pressure of a client who has come to the health care facility for the first time. Which of the following is the best site for obtaining the client's blood pressure reading?

The ability of the arteries to stretch

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?

Reading is erroneously high.

A nurse is assessing the blood pressure on an obese woman. What error might occur if the cuff used is too narrow?

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

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

45 to 60

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?

Ear

A nurse is caring for a client with fever. The nurse is assessing the client's core body temperature. Which of these sites is ideal to assess the client's body temperature?

Orthostatic hypotension

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?

"Have you been sitting for a long time?"

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?

Isolated systolic hypertension

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?

Bradycardia

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?

18 breaths/min

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

Blood pressure.

A nurse takes a patient's vital signs. Which of the following is considered a vital sign?

Assess the patient'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?

decreased body metabolism.

An elderly client is seen by the nurse in the neighborhood clinic. The nurse observes that the client is dressed in several layers of clothing, although the temperature is warm outside. The nurse suspects that the client's cold intolerance is a result of

The blood pressure increases.

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

Palpating the flow of blood through an artery

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

To see the client before the client assumes a social face or behavior

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?

Diet

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

Tympanic

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?

"Are you having pain from your surgery?"

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?

As soon as the examiner first sees the client

When can the general inspection be started?

Ashen gray

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

oral: 37.0°C

Which of the following is an average normal temperature in Centigrade for a healthy adult?

Routine recalibration of the device

You are educating your patient on taking blood pressure at home. What would be important to include in your patient education?