Chapter 8 & 9

A nurse measures a client's blood pressure and obtains a reading of 150/85 mm Hg. Which question should the nurse ask the client in regards to this reading? a) "Do you need to empty your bladder?" b) "Are you currently taking blood pressure medication?" c) "Have you been sitting in this chair for a long time?" d) "What was your blood pressure 1 week ago?"

"Do you need to empty your bladder?" Explanation: Blood pressure can be altered (elevated) with intake of caffeine or nicotine and with a full bladder, walking, or talking. Taking blood pressure medication would lower the blood pressure, not elevate it. Sitting will lower both the pulse rate and the blood pressure. It doesn't matter what the blood pressure was 1 week ago because now it is elevated.

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 a) decreased body metabolism. b) neurologic deficits. c) pancreatic disease. d) recent surgery.

"Have you been sitting for a long time?" Explanation: Sitting or standing for too long may cause the blood to pool and decrease the pulse rate. Fever and stress cause the pulse rate to increase, not decrease. Vitamin supplements do not affect the pulse rate.

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? a) "Are you feeling feverish today?" b) "Have you been sitting for a long time?" c) "What vitamin supplements are you currently taking?" d) "How is your stress level today?

"Have you been sitting for a long time?" Explanation: Sitting or standing for too long may cause the blood to pool and decrease the pulse rate. Fever and stress cause the pulse rate to increase, not decrease. Vitamin supplements do not affect the pulse rate

A nursing instructor is teaching students how to assess a patient's pain. The instructor emphasizes that there are many misconceptions about pain. The instructor realizes that a student needs further direction when the student states: a) "Chronic pain can be referred to as persistent pain." b) "Patients with chronic illnessess can have chronic pain." c) "Nurses are the best authority on pain." d) "Acute pain can be as intense as chronic pain."

"Nurses are the best authority on pain." Explanation: Pain is what the patient says it is, and it exists whenever the patient says it does. The patient is the best authority on pain, and self-report is the gold standard. Therefore, nurses are not authorities on pain. It is true that patients with chronic illnesses can and often do have chronic pain. It also is true that acute pain can be intense. Chronic pain is sometimes known as persistent pain.

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? a) 0 b) 1+ c) 2+ d) 3+

1+ Correct Explanation: Pulse amplitude of 0 means that it is absent, 1+ that it is weak and diminished (easy to obliterate), 2+ that it is normal (can be obliterated with moderate pressure), and 3+ that it is bounding (unable to obliterate or requires firm pressure).

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? a) 140/95 mm Hg in the right arm and 130/85 mm Hg in the left arm b) 118/78 mm Hg in the right arm and 122/80 mm Hg in the left arm c) 118/78 mm Hg in the right arm and 130/84 mm Hg in the left arm d) 140/90 mm Hg in the right arm and 150/96 mm Hg in the left arm

118/78 mm Hg in the right arm and 122/80 mm Hg in the left arm Explanation: Usually, there is a difference in pressure of 5 mm Hg and sometimes up to 10 mm Hg between arms. Pressure difference of more than 10 to 15 mm Hg between arms suggests arterial compression or obstruction on the side with the lower pressure.

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? a) 130/65 mm Hg b) 160/85 mm Hg c) 140/55 mm Hg d) 120/55 mm Hg

120/55 mm Hg Explanation: A drop in both the systolic and diastolic readings of 20 mm Hg or more from the sitting position to the standing position indicates orthostatic hypotension. A drop of less than 20 mm Hg from the sitting position is considered normal. An elevation is not called hypotension but hypertension.

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? a) 120/55 mmHg b) 130/65 mmHg c) 160/85 mmHg d) 140/55 mmHg

120/55 mmHg Explanation: A drop in both the systolic and diastolic readings of 20 mmHg and more indicates orthostatic hypotension. A drop of less than 20 mmHg from the sitting position is considered normal. An elevation is not called hypotension but hypertension.

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? a) 23 b) 12 c) 11 d) 18

18 Explanation: A respiratory rate of 18 breaths/min would be normal for this client. In older adults, the normal respiratory rate would range between 15 and 22 breaths/min. Respiratory rates of fewer than 15 breaths/min or more than 22 breaths/min would be an abnormal respiratory rate for this client.

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? a) 45-60 b) 105-120 c) 65-80 d) 85-100

45-60 Explanation: The normal pulse rate of a well-conditioned athletic client is often 45-60 beats per minute because of the conditioning of the cardiovascular system. A pulse rate ranging between 60 and 100 beats/min is normal for adults. A pulse rate of more than 100 beats/min would indicate tachycardia

A client presents to the health care clinic with reports of 20day history of sore throat pain, ear pressure, fever, and stiff neck. The client states they have taken Tylenol and lozenges without relief. Which nursing diagnosis can be confirmed by this data? a) Impaired Mobility related stiff neck b) Anxiety related to prolonged pain c) Acute Pain related to sore throat d) Risk for Fluid Volume Deficit related to fever

Acute Pain related to sore throat Explanation: The client describes pain on 2 day duration which is within the definition for acute pain. The client did not describe or display any major defining characteristics of anxiety such as restlessness, concern about lifestyle changes, sleep disturbances. The stiff neck was not confirmed by objective data collected by the nurse. No evidence exists for the client to have risk for fluid volume deficit

Common or concerning symptoms to inquire about in the general survey and vital signs include all of the following except: a) Fever b) Adventitious lung sounds c) Level of consciousness d) Weight

Adventitious lung sounds Explanation: Auscultating the lungs is more appropriate during the respiratory review of systems. Weight, temperature, and level of consciousness are all components of the general survey and vital signs

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? a) Alcoholism b) Cushing's syndrome c) Marfan's syndrome d) Parkinson's disease

Alcoholism Explanation: A client may appear older than actual chronologic age due to a hard life, manual labor, chronic illness, alcoholism, or smoking. Parkinson's disease is associated with stiff, rigid movements. Marfan's syndrome is associated with arm span being greater than height and pubis to sole measurement exceeding pubis to crown measurement. Cushing's syndrome is associated with central body weight gain with excessive cervical obesity (Buffalo's hump)

When can the general inspection be started? a) When the client is completely exposed b) As soon as the examiner first sees the client c) During the examiner's preparation to meet the client d) After height and weight have been taken

As soon as the examiner first sees the client Explanation: The first moments of interaction between client and examiner should constitute the beginning of the general inspection. This should not wait until after height and weight have been measured or until the client is completely exposed. It is not possible to begin a general inspection prior to seeing (or smelling or hearing) the client.

Which abnormal skin color should a nurse anticipate assessing on a dark-skinned client? a) Reddish b) Beige-pink c) Ashen gray d) Yellowish

Ashen gray Explanation: The skin of a dark-skinned client with cyanosis would be ashen gray. The skin tone would appear yellowish in a light-skinned client if the client had jaundice. A beige-pink skin tone would be a normal finding for the light-skinned client

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? a) Take the patient's temperature rectally b) Assess the patient's skin tone and the presence or absence of sweating to determine whether the patient is febrile c) Use a disposable mercury thermometer to take the patient's temperature d) Assess the patient's temperature by axilla

Assess the patient's temperature by axilla Explanation: The axillary site is an accurate and acceptable alternative when other sites are impractical or contraindicated. Rectal temperatures are contraindicated in cardiac patients; mercury thermometers are not commonly used. It is unacceptable for the nurse to rely solely on subjective assessments to determine whether the patient is febrile

Ideally, when taking a blood pressure, the patient should be instructed to what? a) Avoid smoking for 30 minutes prior to the assessment b) Abstain from drinking caffeine for 45 minutes prior to the assessment c) Sit quietly for at least 10 minutes in a chair, rather than on the examining table, with feet flat on the floor and legs uncrossed d) Take several deep breaths to help relax prior to the assessment

Avoid smoking for 30 minutes prior to the assessment Explanation: Ideally, instruct the patient to avoid smoking or drinking caffeinated beverages for 30 minutes before the blood pressure is measured.

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? a) Blood pressure cuff is tightly fitted. b) Blood pressure is measured on a bare arm. c) Client is seated quietly for 10 minutes prior to measurement. d) Client's arm is resting, supported by the nurse's arm at the client's mid-chest level.

Blood pressure cuff is tightly fitted. Explanation: A blood pressure cuff that is too tightly fitted can result in a false high reading. Resting prior to assessment, measuring on a bare arm, and supporting the client's arm at mid-chest level all foster accurate BP measurement.

A nurse takes a patient's vital signs. Which of the following is considered a vital sign? a) Visual acuity. b) Urinary output. c) Mental status. d) Blood pressure

Blood pressure. Explanation: Vital signs are a person's temperature, pulse, respiration, and blood pressure. Mental status, visual acuity, and urinary output are not considered vital signs, even though they are frequently assessed

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? a) Tachycardia b) Hypocardia c) Normal d) Bradycardia

Bradycardia Explanation: A heart rate or pulse of 60 beats per minute is termed bradycardia. Normal heart rate for the adult is between 60 and 100 beats per minute. Tachycardia describes a heart rate over 100 beats per minute. Hypocardia refers to a heart that is not beating with enough force.

The nurse is caring for a 22-year-old man with a crush injury. The nurse would be alert for what pain descriptions that would indicate neuropathic pain? a) Gnawing b) Crushing c) Painful numbness d) Burning e) Sharp

Burning • Painful numbness Explanation: Nurses should also be alert for the common terms that patients use to report neuropathic pain such as burning, painful tingling, pins and needles, and painful numbness. Sharp pain is a descriptor of somatic pain, gnawing pain is a description of visceral pain, and crushing pain often indicates a myocardial infarction.

The nurse should assess for which pain complaints from a client diagnosed with Type II Diabetes Mellitus? a) Pain only on movement b) Aching, gnawing c) Sharp, stabbing d) Burning, tingling

Burning, tingling Explanation: The nurse should assess for neuropathic pain associated with diabetic neuropath. Neuropathic pain: Pain that results from damage to nerves in the peripheral or central nervous system (Staats, et al., 2004). Examples of neuropathic pain include diabetic peripheral neuropathy, post herpetic neuralgia, and postmastectomy pain. You should also be alert for the common terms that patients use to report neuropathic pain, such as burning, painful tingling, pins and needles, and painful numbness.

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? a) Osteoporotic thinning b) Chronic pulmonary obstructive disease c) Rheumatoid Arthritis d) Parkinson's disease

Chronic pulmonary obstructive disease Explanation: Chronic pulmonary obstructive disease could be the possible reason for the client tending to lean forward and brace himself with his arms. This is the "tripod position." Stiff, rigid movements are common in clients with arthritis or Parkinson's disease. Osteoporotic thinning is common in elderly clients.

Which technique demonstrates the proper position of the arm by a nurse when measuring a blood pressure? a) Client standing with arm outstretched and at the level of the heart b) Client's arm above the level of the heart and resting on a bedside table c) Client sitting with arm outstretched and even with the heart d) Client's arm bent at the elbow and resting on the thigh

Client sitting with arm outstretched and even with the heart Explanation: Ideally, the blood pressure should be taken with the client in a comfortable position for 5-10 minutes. The blood pressure cuff should be placed against the client's skin with the bladder over the arterial pulsation. The client's arm should be slightly flexed and supported with the nurse's arm. The arm should be at the level of the heart with the palm up

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 a) Date and location of the client's last blood pressure check b) Respiratory rate c) Core body temperature d) Blood pressure e) Onset and character of the client's chest pain f) A list of all of the client's current medications

Date and location of the client's last blood pressure check • Onset and character of the client's chest pain • A list of all of the client's current medications Explanation: Subjective findings, which are those the client must report to the nurse, include date and location of the client's last blood pressure check, the onset and character of the client's chest pain, and a list of all of the client's current medications. Objective findings, which are obtained by the nurse's direct observation or assessment, include respiratory rate, core body temperature, and blood pressure.

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? a) Depression b) Risk for Self related Violence c) Impaired Verbal Communication d) Imbalanced Nutrition: Less than Body Requirements

Depression Explanation: The major defining characteristics of depression are present: loss of sleep, feeling unsafe, inability to concentrate, and poor eye contact. There are no major characteristics for the nursing diagnosis of Impaired Nutrition: Less than Body Requirements, Risk for Self related Violence, or Impaired Verbal Communication.

Body temperature is not impacted by which of the following factors? a) Diurnal cycle b) Physical activity c) Age d) Diet

Diet Explanation: Body temperature varies with diurnal cycle, physical activity, age, gender, and state of health. It also normally fluctuates with activity and time of day. Of the choices offered, the only correct answer is diet.

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? a) Give oxygen at 2 liters per nasal cannula b) Document the finding c) Notify the physician immediately d) Lower the head of the bed

Document the finding Explanation: A well-conditioned athlete may have a heart rate in the range of 50 to 60 bpm. It would not be appropriate to notify the physician immediately, give the patient oxygen, or lower the head of the bed.

When counting the patient's pulse, what beats may be difficult to detect peripherally? a) Late beats b) Split beats c) Irregular beats d) Early beats

Early beats Explanation: Beats that occur earlier than others may not be detected peripherally, and the heart rate can be seriously underestimated.

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? a) Decreased height and skeletal malformations b) Increased fat distribution in the chest, stomach and neck c) Elongated bones of the face and hands d) Elongated fingers

Elongated fingers Explanation: Marfan's syndrome is characterized by elongated limbs and fingers. Elongated bones of the face and hands are associated with acromegaly. Client's with Cushing's syndrome exhibit weight gain in the chest, stomach and neck. Decreased height and skeletal malformations are associated with dwarfism.

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? a) Elongated bones of the face and hands b) Increased fat distribution in the chest, stomach and neck c) Decreased height and skeletal malformations d) Elongated fingers

Elongated fingers Explanation: Marfan's syndrome is characterized by elongated limbs and fingers. Elongated bones of the face and hands are associated with acromegaly. Client's with Cushing's syndrome exhibit weight gain in the chest, stomach and neck. Decreased height and skeletal malformations are associated with dwarfism.

A client on a medical-surgical unit reports pain of 10 on a scale of 0 to 10 and wants more pain medication. The nurse does not think the pain is as bad as the client says. The physician left orders for prn morphine for breakthrough pain. What is the priority nursing action? a) Call the physician to check the order b) Give the prn morphine c) Hold the medication and wait 30 minutes d) Document the client's pain rating on a scale of 0 to 10

Give the prn morphine Explanation: Pain is what the client says it is, and it exists whenever the client says it does. It would not be appropriate to hold the medication for 30 minutes, call the physician to check the order, or just document the client's pain.

The nurse explains to the client that smoking has what effect on the body? Select all that apply. a) Vasoconstriction b) Peripheral vascular disease c) Vasodilation d) Hypertension e) Hypotension

Hypertension • Vasoconstriction • Peripheral vascular disease Explanation: Smoking can cause vasoconstricion, hypertension and peripheral vascular disease, not vasodilation and hypotension

The client is exercising. The nurse understands that exercise has what effect on the body? Select all that apply. a) Increased cardiac output b) Increased blood pressure c) Increased heart rate d) Increased peripheral vascular resistance e) Decreased cardiac output

Increased heart rate • Increased blood pressure • Increased cardiac output Explanation: During exercise, the blood pressure, heart rate and cardiac output increase. Peripheral vascular resistance is related to circulatory disorders.

The nursing assistant obtains vital signs and reports a blood pressure of 180/95 to the nurse. What is the nurse's best action? a) Ask the nursing assistant to check for symptoms of hypertension. b) Notify the healthcare provider immediately. c) Instruct the nursing assistant to obtain a manual blood pressure. d) Document the blood pressure as an expected finding.

Instruct the nursing assistant to obtain a manual blood pressure. Explanation: The best action is to verify the finding with a manual blood pressure before notifying the healthcare provider. The blood pressure is elevated and the RN should take action. The RN may delegate individual components of care, such as obtaining vital signs, but does not delegate the nursing process itself. Asking the nursing assistant to check for symptoms of hypertension is delegating assessment. Assessment is a component of the nursing process for which the RN is responsible for performing.

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? a) Normal for the elderly b) Stage I hypertension c) Orthostatic hypotension d) Isolated systolic hypertension

Isolated systolic hypertension Explanation: The elderly are prone to isolated systolic hypertension (systolic greater than 140 but diastolic under 90) due to arteriosclerosis that makes blood vessels stiff and less compliant. Orthostatic hypotension is a blood pressure that drops when a client changes positions. Stage 1 hypertension is a blood pressure reading of 140 to 159/90 to 99 mm Hg. Hypertension is not normal for any client

A patient who has had a recent below-knee amputation tells the nurse that he feels as though his toes are cramping. What would the nurse say in return? a) "Oh, that is all in your mind. Just forget it." b) "That is called phantom pain, and it is not unusual." c) "I think it might be good to refer you to a psychiatrist." d) "Well, that is really strange. I will notify the doctor."

Joint Commission Standards for Pain Management. Explanation: Joint Commission Standards for Pain Management were revised and published in 2000-2001. The standards require health care providers and organizations to improve pain assessment and management for all patients.

A nurse obtains a client's blood pressure (BP) on admission in both arms: right arm BP is 130/75 mm Hg and left arm BP is 140/80 mm Hg. Which arm should the nurse use for subsequent blood pressure reading? a) Left arm b) Right arm c) Dominant arm d) Both arms

Left arm Explanation: Blood pressure should be taken in the dominant arm first (right arm for most people). When assessing for the first time, BP should be measured in both arms. Subsequent readings should be taken in the arm with the highest measurement.

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? a) Gigantism b) Marfan's syndrome c) Anorexia d) Cushing's syndrom

Marfan's syndrome Explanation: Arm span is greater than height and pubis to sole measurement exceeds pubis to crown measurement in Marfan's syndrome. In gigantism, there is increased height and weight with delayed sexual development. Extreme weight loss is seen in anorexia nervosa. Central body weight gain with excessive cervical obesity (Buffalo's hump), also referred to as endogenous obesity, is seen in Cushing'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? a) Marfan's syndrome b) Cushing's syndrome c) Anorexia d) Gigantism

Marfan's syndrome Explanation: Arm span is greater than height and pubis to sole measurement exceeds pubis to crown measurement in Marfan's syndrome. In gigantism, there is increased height and weight with delayed sexual development. Extreme weight loss is seen in anorexia nervosa. Central body weight gain with excessive cervical obesity (Buffalo's hump), also referred to as endogenous obesity, is seen in Cushing's syndrome

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? a) Reassess patient in one hour b) Infuse IV fluids c) Administer diuretics d) Notify the rapid response team

Notify the rapid response team Explanation: The client is in distress. The most appropriate action of the nurse is to notify the rapid response team. The nurse cannot administer IV fluids or medications without an order Reassessing in one hour is not an appropriate action due to the client's condition

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 a) A list of all of the client's current medications b) Core body temperature c) Respiratory rate d) Onset and character of the client's chest pain e) Date and location of the client's last blood pressure check f) Blood pressure

Onset and character of the client's chest pain • Date and location of the client's last blood pressure check • A list of all of the client's current medications Explanation: Subjective findings, which are those the client must report to the nurse, include date and location of the client's last blood pressure check, the onset and character of the client's chest pain, and a list of all of the client's current medications. Objective findings, which are obtained by the nurse's direct observation or assessment, include respiratory rate, core body temperature, and blood pressure.

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? a) Dyspnea b) Secondary hypertension c) Orthostatic hypotension d) Primary hypertension

Orthostatic hypotension Explanation: 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

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? a) Ambulatory bradycardia b) Orthostatic hypotension c) Orthostatic hypertension d) Ambulatory tachycardia

Orthostatic hypotension Explanation: 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.

Assessment of the pulse amplitude is accomplished by which of the following? a) Auscultating the flow of blood through an artery b) Palpating the flow of blood through an artery c) Palpating the area of the left ventricle d) Auscultating the area of the left ventricle

Palpating the flow of blood through an artery Explanation: The pulse amplitude describes the quality of the pulse in terms of its fullness and reflects the strength of left ventricular contraction. It is assessed by the feel of the blood flowing 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? a) Palpitation b) Dyspnea c) Apical beats d) Pulse pressure

Palpitation Explanation: An alteration in heartbeat felt by a client is called a palpitation and can be caused by various circumstances including thyroid dysfunction, medication reaction, or alteration in fluid volume. Dyspnea is difficulty breathing. Pulse pressure is the difference between systolic and diastolic blood pressures. Apical beats are simply the beats of the heart palpated directly over the apex of the heart, on the chest

When assessing a client's respiration, what is most important to include in the documentation? a) Position of the client b) Numerical pain rating c) Assessment of pedal pulses d) Presence of dyspnea

Presence of dyspnea Explanation: The presence of dyspnea is the most important of the choices listed to include in the documentation. Dyspnea can be an indicator of potential respiratory distress. The presence of pain and position of the client can impact the client's respiratory status, but are not the primary piece of information to include in the documentation. Assessment of pedal pulses is a component of a circulatory assessment

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? a) Pulse is felt with difficulty and disappears with slight pressure. b) Pulse is felt easily, and moderate pressure causes it to disappear. c) Pulse is strong, and light pressure causes it to disappear. d) Pulse is strong and remains despite moderate pressure.

Pulse is felt with difficulty and disappears with slight pressure. Explanation: 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.

When assessing a client's pulse, the nurse should be alert to which of the following characteristics? a) Pain, temperature, amplitude and contour, and elasticity. b) Rate rhythm, temperature, rigidity, color, and elasticity. c) Rate, rhythm, amplitude and contour, and elasticity. d) Tenderness, moistness, contour, elasticity, pressure.

Rate, rhythm, amplitude and contour, and elasticity. Explanation: Several characteristics should be assessed when measuring the radial pulse: rate, rhythm, amplitude and contour, and elasticity.

When assessing a client's pulse, the nurse should be alert to which of the following characteristics? a) Tenderness, moistness, contour, elasticity, pressure. b) Rate rhythm, temperature, rigidity, color, and elasticity. c) Pain, temperature, amplitude and contour, and elasticity. d) Rate, rhythm, amplitude and contour, and elasticity.

Rate, rhythm, amplitude and contour, and elasticity. Explanation: Several characteristics should be assessed when measuring the radial pulse: 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? a) Reading is erroneously low. b) Reading is erroneously high. c) Pressure on the cuff would be painful. d) It will be difficult to pump up the bladder.

Reading is erroneously high. Explanation: 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.

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? a) Retake the blood pressure b) Document the findings c) Notify the physician immediately d) Give PRN blood pressure medications

Retake the blood pressure Explanation: When encountering an abnormal value, obtain the vital sign(s) again to assess accuracy. It would be inappropriate to notify the physician immediately, give PRN blood pressure medications, or document the findings before rechecking the reading.

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? a) Resilient b) Springy c) Rigid d) Straight

Rigid Explanation: The older client's artery may feel more rigid, hard, and bent. More rigid, arteriosclerotic arteries account for higher systolic blood pressure in older adults. Normal arteries should feel resilient, straight, and springy.

You are educating your patient on taking blood pressure at home. What would be important to include in your patient education? a) Application of a thigh cuff b) Monthly replacement of batteries c) Use of a wrist cuff d) Routine recalibration of the device

Routine recalibration of the device Explanation: Follow the guidelines listed, and advise your patients about how to choose the best cuff for home use. Urge them to have their home devices recalibrated routinely.

In preparation to take the National Council Licensure Examination for registered nurses, the nurse should be able to assist clients with which basic care activities? (Select all that apply.) a) Personal hygiene b) Sleep and rest c) Communication d) Using assistive devices e) Preventing pressure ulcers

Sleep and rest • Communication • Personal hygiene • Using assistive devices Explanation: The items included in assessment as part of the basic care activities include the following: activities of daily living and assistive devices; sleep/rest; communication/speeck, vision, and hearing; personal hygiene habits and routine. Preventing pressure ulcers is considered a national safety goal to reduce risk and promote health.

A patient recovering from abdominal surgery is complaining of pain. The nurse realizes that the patient is most likely experiencing which type of pain? a) Idiopathic b) Somatic c) Neuropathic d) Psychogenic

Somatic Explanation: Somatic pain is caused by tissue damage, which would occur after abdominal surgery. Psychogenic pain relates to factors that influence the patient's report of pain such as anxiety and depression. Idiopathic pain does not have an identified cause. Neuropathic pain results from direct injury to the peripheral or central nervous system.

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? a) Stage 2 Hypertension b) Stage 1 Hypertension c) Stage 3 Hypertension d) Normal

Stage 2 Hypertension Explanation: The client's blood pressure falls between the ranges of 160 to 179 systolic or 100 to 109 diastolic. Therefore, the blood pressure of the client can be classified as Stage 2 Hypertension. Normal blood pressure measurement should be less than 130 systolic and less than 85 diastolic. Stage 1 Hypertension measurement should be between 140 to159 systolic and 90 to 99 diastolic. Stage 3 Hypertension measurements should be greater than or equal to180 systolic and greater than or equal to 110 diastolic

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? a) Past surgeries b) State of health c) Safety d) Growth pattern

State of health Explanation: Anthropometric measurements are the various measurements of the human body, including height and weight. They provide critical information about the adult's state of health. Accurate measurements do not provide critical information about safety, past surgeries, or growth pattern in the adult client.

Various sounds are heard when assessing a blood pressure. What does the first sound heard through the stethoscope represent? a) Systolic pressure b) Auscultatory gap c) Diastolic pressure d) Pulse pressure

Systolic pressure Explanation: The first sound heard through the stethoscope, which is the onset of phase I of Korotkoff sounds, represents the systolic pressure.

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? a) Systolic pressure 180 mm Hg. b) Oxygen saturation 95% on room air. c) Apical pulse 70 beats/minute. d) Respirations 12 breaths/minute.

Systolic pressure 180 mm Hg. Explanation: The nurse may call a rapid response team if the client displays the following: respirations less than 10 breaths/min; oxygen saturation less than 92%; pulse less than 55 beats/min or greater than 120 beats/min; systolic blood pressure less than 100 or greater than 170 mm Hg.

When measuring a client's pulse rate, the nurse records 125 bpm. How will the nurse document the information in the medical records? a) Slow pulse rate b) Bradycardia c) Heart palpitations d) Tachycardia

Tachycardia Explanation: Tachycardia (100 to 150 bpm) is a fast heart rate. In tachycardia, the heart and pulse rates can exceed 150 bpm as well. Bradycardia, or a slow pulse rate, occurs in adults if the heart rate falls below 60 bpm. Heart palpitations represent the physical sensation of irregularities in the beating of the heart.

In which order should a nurse assess a client's vital signs? a) Temperature, pulse, respiration, and blood pressure b) Pulse, temperature, respiration, and blood pressure c) Respiration, blood pressure, pulse, and temperature d) Blood pressure, temperature, pulse, and respiration

Temperature, pulse, respiration, and blood pressure Explanation: When assessing the vital signs of the client, the nurse should begin by measuring the client's temperature, to put the client at ease and to quiet the client for better assessment of the remaining vital signs. Pulse, respiration, and blood pressure can be altered by anxiety and activity.

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? a) The volume of air entering the lungs b) The oxygen levels in the blood c) The thickness of the circulating blood d) The ability of the arteries to stretch

The ability of the arteries to stretch Explanation: 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.

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 is erratic. b) The blood pressure decreases. c) The blood pressure does not change. d) The blood pressure increases.

The blood pressure increases. Explanation: 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 that is reflected in an increased blood pressure.

A client with an amputated arm tells a nurse that sometimes he experiences throbbing pain or a burning sensation in the amputated arm. What kind of pain is the client experiencing? a) Neuropathic pain b) Chronic pain c) Cutaneous pain d) Visceral pain

The client is experiencing neuropathic pain or functional pain. Neuropathic pain is often experienced days, weeks, or even months after the source of the pain has been treated and resolved. The client is not experiencing cutaneous, visceral, or chronic pain. In cutaneous pain, the discomfort originates at the skin level. In visceral pain, the discomfort arises from internal organs caused from a disease or injury. In chronic pain the discomfort lasts longer than 6 months.

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? a) Monitoring blood pressure every 4 hours is sufficient for this client b) The nurse can delegate monitoring of the client's blood pressure to the patient care assistant c) The nurse will assess blood pressure more frequently to ensure that it does not go beyond the ordered limits d) Monitoring blood pressure once every hour is sufficient for this client

The nurse will assess blood pressure more frequently to ensure that it does not go beyond the ordered limits Correct Explanation: Vital signs reflect health status, cardiopulmonary function, and overall body function. They are called vital signs because of their importance as indicators of physiological state and response to physical, environmental, and psychological stressors. Changes in vital signs often indicate changes in health. Assessment of vital signs helps nurses to establish a baseline, monitor a client's condition, evaluate responses to treatment, identify problems, and monitor risks for alterations in health. It would not be appropriate to monitor this client's BP every hour or every 4 hours or to delegate the taking of this client's BP to a patient care assistant.

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? a) There is an adult diastolic b) There is an auscultatory gap c) There is a nonauscultatory gap d) There is a widening in the diameter of the artery

There is an auscultatory gap Explanation: An auscultatory gap is a period during which sound disappears. An auscultatory gap can range as much as 40 mm Hg. A widening in the diameter of the artery takes place in the phase II of the Korotkoff's sounds technique. An adult diastolic pressure takes place in the phase IV of the Korotkoff's sounds technique.

The nurse is assessing a client's respiratory rate. Which of the following should the nurse do to ensure accuracy of this assessment? a) Ask the client to breathe normally b) Perform the assessment at the beginning, middle, and end of the examination and average the results c) Observe the client's chest movement before calling the client back to the examination room d) Watch chest movement before removing the stethoscope after counting the apical beat

Watch chest movement before removing the stethoscope after counting the apical beat Explanation: Because breathing is under voluntary in addition to autonomic control, clients may intentionally or inadvertently alter their breathing rate if they are aware that it is being assessed. To obtain an accurate assessment, observe respirations without alerting the client by watching chest movement before removing the stethoscope after you have completed counting the apical beat. Asking the client to breathe normally may still make the client self-conscious and prevent an accurate measurement. Observing the client's chest movement before calling the client back to the examination room would not be practical due to the distance. Performing the assessment multiple times is unnecessary and time consuming

When assessing the client for pain, the nurse should a) assess for underlying causes of pain, then believe the client. b) assess for the presence of physiologic indicators (such as diaphoresis, tachycardia, etc.), then believe the client. c) believe the client when he or she claims to be in pain. d) doubt the client when he or she describes the pain.

believe the client when he or she claims to be in pain. Explanation: "Pain is whatever the person says it is." It is important to remember this definition when assessing and treating pain.

A client's blood pressure is affected by a) cardiac output, distensibility of the veins, blood volume, blood velocity and viscosity. b) cardiac output, distensibility of the arteries, blood volume, blood velocity and viscosity. c) cardiac intake, elasticity of the veins, blood flow, blood cells, and blood thickness. d) cardiac intake, elasticity of the arteries, blood flow, blood cells, and blood thickness.

cardiac output, distensibility of the arteries, blood volume, blood velocity and viscosity. Explanation: Blood pressure is affected by cardiac output, distensibility of the arteries, blood volume, blood velocity, and blood viscosity (thickness).

Osteoporotic thinning and collapse of the vertebrae secondary to bone loss in an elderly client may result in a) kyphosis b) skeletaldosis c) lordosis d) scoliosis

kyphosis Explanation: In older adults, osteoporotic thinning and collapse of the vertebrae secondary to bone loss may result in kyphosis.

The nurse is preparing to assess the respirations of an alert adult client. The nurse should a) observe for equal bilateral chest expansion of 2.54 to 5.08 cm (1 to 2 in). b) explain to the client that he or she will be counting the client's respirations. c) ask the client to lie in a supine position, which makes counting the respirations easier. d) count for 15 seconds and multiply the number by 4 to obtain the rate

observe for equal bilateral chest expansion of 2.54 to 5.08 cm (1 to 2 in). Correct Explanation: When observing respiratory depth the nurse should assess for equal bilateral chest expansion of 1 to 2 inches.

Which of the following is an average normal temperature in Centigrade for a healthy adult? a) tympanic: 34.4°C b) oral: 37.0°C c) axillary: 37.5°C d) rectal: 36.5°C

oral: 37.0°C Correct Explanation: 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.

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 a) supine hypotension b) hypertensive crisis c) postural hypertension d) orthostatic hypotension

orthostatic hypotension

The client is exercising. The nurse understands that exercise has what effect on the body? Select all that apply. a) Increased heart rate b) Increased peripheral vascular resistance c) Increased cardiac output d) Increased blood pressure e) Decreased cardiac output

• Increased blood pressure • Increased cardiac output • Increased heart rate Explanation: During exercise, the blood pressure, heart rate and cardiac output increase. Peripheral vascular resistance is related to circulatory disorders.

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. a) The client has hypothyroidism. b) The client just finished exercising. c) The client is hypoglycemic. d) The client is ovulating. e) The client is stressed. f) The client is starving.

• The client just finished exercising. • The client is ovulating. • The client is stressed. Explanation: Several factors may cause normal variations in the core body temperature. Strenuous exercise, stress, and ovulation can raise temperature. Body temperature is lowest early in the morning (4:00 to 6:00 AM) and highest late in the evening (8:00 PM to midnight). Hypothermia (lower than 36.5°C or 96.0°F) may be seen in prolonged exposure to the cold, hypoglycemia, hypothyroidism, or starvation. Hyperthermia (higher than 38.0°C or 100°F) may be seen in viral or bacterial infections; malignancies; trauma; and various blood, endocrine, and immune disorders