Chapter 8 Assessment

Which general survey question focuses on the common "fifth vital sign"?

"Are you experiencing any pain right now?"

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?

"Are you having pain from your surgery?"

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?

"Do you need to empty your bladder?"

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?

"Have you been sitting for a long time?"

Which general survey questions will provide the nurse information regarding the client's personal makeup? Select all that apply.

"What ethnic culture do you identify with?"

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?

1+

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?

18

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?

45 to 60

A nurse has assessed the blood pressure of a recently admitted client and obtained a reading of 128/78 mm Hg. What is this client's pulse pressure?

50 mm Hg

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?

Anxiety

Before assessing vital signs, the nurse knows that it is important to assess what?

Any medications the client is currently taking

When can the general inspection be started?

As soon as the examiner first sees the client

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

Ashen gray

A client has arrived to the clinic for a routine physical examination. Prior to assessing the client's blood pressure, what should the nurse do?

Ask the client to sit quietly in a chair for 5 minutes.

An 86-year-old male client with a diagnosis of vascular dementia and cardiomyopathy is exhibiting signs and symptoms of pneumonia. The nurse has attempted to assess his temperature using an oral thermometer but the client is unable to follow directions to close his mouth and secure the thermometer sublingually. As well, he repeatedly withdraws his head when the nurse attempts to use a tympanic thermometer. How should the nurse proceed with assessment?

Assess the client's temperature by axilla

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

Blood pressure

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?

Blood pressure cuff is tightly fitted.

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?

Bradycardia

During the physical assessment of a client, a nurse observes that the client tends to lean forward, using the arms to support the upper body. The nurse recognizes this as a sign of what disease process?

Chronic obstructive pulmonary disease

Which technique demonstrates the proper positioning of the client's arm by a nurse when measuring a blood pressure?

Client sitting with arm slightly flexed and even with the heart

On which health problem should the nurse focus when assessing this client?

Cushing's syndrome

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

Cyanotic left lower extremity

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

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

The nurse should know that some disease processes affect facial expression. What are they? (Mark all that apply.)

Depression Parkinsonism Hyperthyroidism

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

Diet

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.)

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

The nurse is reviewing the chart of a newly admitted client and identifies the client has Marfan syndrome. What assessment finding would the nurse expect to find?

Elongated fingers

A nurse is teaching a class on hypertension in a community setting. What risk factor would the nurse be sure to address to the class?

Family history

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 client's vital signs to be what?

Higher than normal

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

Increased heart rate Increased blood pressure Increased cardiac output

Upon assessing a client who is hemorrhaging, the nurse is most likely to assess which compensatory change in vital signs?

Increased pulse rate

The nursing assistant obtains vital signs and reports a blood pressure of 180/95 to the nurse. What is the nurse's best action?

Instruct the nursing assistant to obtain a manual blood pressure.

During general inspection, the examiner:

Integrates visual, auditory, and olfactory data

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?

Isolated systolic hypertension

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?

Left arm

Before completing the physical examination, the nurse determines that the client is awake, alert, and oriented. This information would be important for which part of the general survey?

Level of consciousness

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?

Marfan syndrome

The nurse is providing care for an 83-year-old woman with a history of hypotension who has been admitted to hospital following a fall. The nurse recognizes the need to assess for orthostatic hypotension. How should the nurse perform this assessment?

Measure the client's heart rate and blood pressure while supine then within 3 minutes of standing.

The nurse observes unlicensed assistive personnel (UAP) at a client's bedside. Which action is UAP performing as depicted in this picture?

Measuring radial pulse

A client recovering from a stroke complains of pain. The nurse suspects this client is most likely experiencing which type of pain?

Neuropathic

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?

Normal readings vary according to age

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?

Notify the rapid response team

A nurse is caring for a client who is ambulating for the first time after surgery. Upon standing, the client complains of dizziness and faintness. The client's blood pressure is 90/50. What is the name for this condition?

Orthostatic hypotension

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 of the following health problems should the nurse consider when client falls occur?

Orthostatic hypotension

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

Palpating the flow of blood 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?

Palpitation

A nurse observes the gait of an elderly client admitted for surgery. The client's gait is stiff with rigid movements. The nurse should ask this client questions about which disease?

Parkinson's disease

A client rates the current pain level as being a 5 on the Numeric Rating Scale. How should the nurse document this pain assessment?

Patient rated pain level as being a 5 using the rating scale.

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

Presence of dyspnea

Since the nurse is unable to obtain an oversized cuff to assess an adult client with a large arm, the nurse uses an average-sized cuff. What blood pressure reading will the nurse most likely obtain for this client?

Reading will be high

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?

Retake the blood pressure

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?

Rigid

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

Routine recalibration of the device

A client recovering from abdominal surgery is complaining of pain. The nurse realizes that the client is most likely experiencing which type of pain?

Somatic

A nurse measures a client's blood pressure at 174/102 mm Hg. The nurse recognizes this as what classification of blood pressure measurement?

Stage 2 hypertension

A student nurse assesses a blood pressure on an adult and finds it to be 140/86. What term is used for the top number (140)?

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?

Systolic pressure 180 mm Hg.

A nurse is preparing to assess a client's vital signs. In which order should the nurse assess them?

Temperature, pulse, respirations, and blood pressure

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?

The ability of the arteries to stretch

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

The blood pressure increases.

A client has an oral temperature of 37.2 °C (99 °F). The nurse interviews the client. Which of the following pieces of interview data could be an influence on this high body temperature?

The client has just run 4.82 km (3 miles) outside before coming to the interview.

During a general survey, the nurse asks if the client is feeling cold. What did the nurse most likely observe in the client?

The client is wearing clothing that is inconsistent with warm weather.

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.

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

The nurse is assessing a new client's blood pressure using a manual sphygmomanometer. Which of the following sounds constitutes the client's systolic blood pressure?

The first appearance of faint but distinctive tapping sounds

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 greater than 90 but less than 120." How does this order affect the monitoring of the client's blood pressure?

The nurse will assess blood pressure more frequently to ensure that it does not go beyond the ordered limits

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?

There is an auscultatory gap

When assessing a client's pulse, the nurse is able to palpate the pulse for some time before losing it upon exerting a little bit more pressure. The pulse is beating at 80 bpm. Which of these should the nurse document as the character of the client's pulse?

Thready pulse

What is the importance of assessing vital signs? (Select all that apply.)

To establish a baseline To monitor risks for alterations in health To evaluate the client's responses to treatment

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?

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

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?

Tympanic

The nurse recognizes that assessment of core body temperature is quick, noninvasive, and safe using which method?

Tympanic

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

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

The nurse begins a client assessment by conducting a general survey that focuses on objective observations. What is the primary purpose for collecting this sort of information first?

assists the nurse in formulating appropriate subjective questioning

A client's blood pressure is affected by

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

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

decreased body metabolism.

The nurse is preparing to assess an adult client in the clinic. The nurse observes that the client is wearing lightweight clothing that is worn and soiled, although the temperature is below freezing outside. The nurse anticipates that the client may be

lacking adequate finances.

The nurse is preparing to assess the respirations of an alert adult client. The nurse should

observe for equal bilateral chest expansion of 2.54 to 5.08 cm (1 to 2 in).

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

oral: 37.0°C

The current blood pressure measurement on a 24-hour uncomplicated postoperative client 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:

orthostatic hypotension.

What information concerning a client's respirations should the nurse record after completing a general physical assessment?

rate, rhythm, and depth of respirations taken for a full minute

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

record the 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

vital signs.