Prep-U Ch. 25 Vital Signs
A nurse is taking the vital signs of a 9-year old child who is anxious about the procedures. Which nursing action would be appropriate when assessing this child?
Perform the blood pressure measurement last.
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.
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 ability of the arteries to stretch
When assessing an infant's axillary temperature, it will be:
1°F (0.5°C) lower than an oral temperature.
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?
Assess the apical pulse.
The nurse needs to obtain an admission weight for a client diagnosed with end-stage lung cancer. To obtain the client's weight, what should the nurse do first?
Assess the client's ability to stand or sit.
A nurse attempts to count the respiratory rate of a client via inspection and finds that the client is breathing at such a shallow rate that it cannot be counted. What is an alternative method of determining the respiratory rate for this client?
Auscultate lung sounds, count respirations for 30 seconds, and multiply by 2.
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.
A nurse is assessing the respirations of a 60-year-old female client and finds that the client's breaths are so shallow that the respirations cannot be counted. What would be the appropriate initial nursing intervention in this situation?
Auscultate the lung sounds and count respirations.
Which statement describes diastolic blood pressure?
During ventricular relaxation, blood pressure is due to elastic recoil of the vessels.
The nurse has just measured an adult client's oral temperature and obtained a result of 102.4ºF (39.1ºC). The client states, "I just finished my coffee right before you came in. Can I have another cup?" Which response by the nurse is most appropriate?
I will bring you another cup when I return in 30 minutes to reassess your temperature. Please do not drink any other beverages until I return."
A client monitoring his BP at home notices that his BP is higher in one arm than the other. He calls his health care provider for guidance. What is the most appropriate information for the nurse to give this client?
It has been found that most people have differences in BP between arms and that he should use the arm that gives him the highest reading for accurate results.
A nurse is caring for an adult with fever. The nurse determines that which site is most ideal for obtaining the client's core body temperature?
Rectum
Which statement is true regarding the autonomic nervous system and its effect on the rate of a person's pulse?
Sympathetic nervous system activation occurs in response to a variety of stimuli, including changes in intravascular volume.
The nurse is checking the client's temperature. The client feels warm to touch. However, the client's temperature is 98.8°F (37.1°C). Which statement could explain this?
The client is covered with a couple of thick blankets.
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 sits in the chair with feet flat on the floor and arm below the level of the heart.
A nurse will assess the oral temperature of a postoperative client. Prior to performing this assessment, which should the nurse identify?
The client's most recent temperature
A nurse needs to count a client's heart rate. For which reason would the nurse assess the client's apical pulse?
The radial pulse is difficult to obtain.
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 resistance that the client's heart must overcome when pumping blood
The student nurse is having difficulty feeling the pedal pulse of the client with a fractured leg. What should the nurse do next?
Use the Doppler ultrasound device.
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?
Wait for 15 to 20 minutes before measuring the oral temperature
Which client would the nurse consider at risk for low blood pressure?
a client with low blood volume
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 apical pulse
Which is not a characteristic used to describe the pulse?
depth
The nurse knows that a client who is being taught to perform home blood pressure monitoring (HBPM) understands the teaching plan when he makes which statement about the size of the BP cuff? The cuff should:
fit snug around the upper arm with room to slip a fingertip under the cuff and should be 1 in (2.5 cm) above the crease of the elbow.
Which outcome best reflects achievement of the goal, "The client will demonstrate correct steps in taking his own pulse rate"?
palpation of the radial pulse on the thumb side of the inner aspect of the wrist.
Nurse T. has auscultated Mr. Weinstein's apical pulse while a colleague simultaneously palpated his radial pulse. This assessment of Mr. Weinstein's apical-radial pulse indicates that the two values differ significantly, a finding that suggests which health problem?
peripheral vascular disease
The nurse understands that accurate blood pressure taking is dependent on several factors. Which example will most likely render an accurate blood pressure reading?
placing the client's arm at heart level
Which term indicates a potentially serious client condition?
pyrexia
The nurse is assessing a new client's blood pressure, using a manual sphygmomanometer. Which sound constitutes the client's systolic blood pressure?
the first appearance of faint but distinctive tapping sounds
