Fundamental of Nursing Taylor Chapter 26 Vital Signs (PrepU)
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39 Terms
Based upon circadian rhythms, when would the nurse note the highest temperature during a 24-hour period?
- 3:00 AM
- 11:00 AM
- 3:00 PM
- 5:00 PM
- 5:00 PM
Body temperature fluctuates throughout the day. Temperature is usually lowest around 0300 and highest from late afternoon to evening.
A client has had a left-side mastectomy. How does this affect the blood pressure assessment?
- Assess the blood pressure in the wrist
- There is no effect on the blood pressure
- Assessment of blood pressure is impeded
- The blood pressure stays within normal range
- Assessment of blood pressure is impeded
Explanation:
If the client has had a mastectomy, blood-pressure monitoring on the same side can further impede circulation, contributing to lymphedema.
A patient informs the nurse that she still uses a mercury thermometer to take the temperature of her children when they are sick. Which of the following is a recommended teaching guideline for patients using these types of thermometers?
- Teach patient safety related to accidental breakage of the thermometer.
- Tell patients using mercury thermometers to throw them in the trash and buy a new type of instrument.
- Encourage patients to use alternative devices to assess temperature in their home.
- Tell patients that mercury thermometers should be used only in a hospital setting with appropriate safeguards.
- Encourage patients to use alternative devices to assess temperature in their home.
Explanation:
It is important to note that glass thermometers with a mercury bulb have been used in the past for measuring body temperature. They are not used in healthcare institutions, based on federal safety recommendations (U.S. Environmental Protection Agency [EPA], 2009). However, patients may still have mercury thermometers at home and may be continuing to use them. Nurses should encourage patients to use alternative devices to measure body temperature and include patient teaching as part of nursing care. Mercury thermometers should not be thrown in the trash because mercury is toxic.
Assessment of the pulse amplitude is accomplished by which of the following?
- Palpating the flow of blood through an artery
- Auscultating the area of the left ventricle
- Palpating the area of the left ventricle
- Auscultating the flow of blood through an artery
- 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.
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?
- Ear
- Rectum
- Axilla
- Mouth
- Rectum
Explanation:
The rectal temperature, a core temperature, is considered to be one of the most accurate routes.
A client monitoring his BP at home notices that his BP is higher in one arm than the other so 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.
- It has been found that most people have differences in BP between arms and that he should use the arm that gives him the lowest reading for accurate results.
- This has no impact on BP readings and he should continue doing what he has been doing.
- This is unusual and should be seen about as soon as possible.
- 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.
Explanation:
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.
The nurse is teaching the parents of an infant with an irregular heartbeat how to check the pulse rate. The infant's pulse is very high and irregular. What will the nurse have to do in order to teach these parents how to monitor their infant's pulse rate?
- This infant will need a home cardiac monitor set up.
- The parents should be encouraged to get a neighbor or family member to help them check their infant's pulse.
- The parents will have to be taught how to use a stethoscope so that they can listen to and count the infant's apical pulse.
- The parents will not be able to check the pulse accurately, the nurse will need to have home health check on this infant on a periodic basis.
- The parents will have to be taught how to use a stethoscope so that they can listen to and count the infant's apical pulse.
Explanation:
If a peripheral pulse is difficult to assess accurately because it is irregular, weak, or very rapid, the apical rate should be assessed using a stethoscope. An apical pulse is also assessed when giving medications that alter heart rate and rhythm. Apical pulse measurement is also the preferred method of pulse assessment for infants and children younger than 2 years of age. Families can be taught to use a stethoscope to check a pulse. This infant does not need a cardiac monitor, the parents should not be encouraged to get a neighbor or family friend to help, and these parents can be taught to check this infant's pulse accurately.
Chapter 24: Vital Signs - Page 590
A nurse documents the following assessment for an infant: temperature 98.9° F (37.2° C), pulse 90 bpm, respirations 35 bpm, and blood pressure 85/73. What is the next appropriate action of the nurse based on these assessments?
- Report an abnormal temperature.
- Report abnormal pulse and respirations.
- Report low blood pressure reading.
- No action is needed; these are normal assessments.
- No action is needed; these are normal assessments.
Explanation:
All of these measurments are within the normal ranges for an infant.
Chapter 24: Vital Signs - Page 581
A nurse is assessing the respirations of a 60-year-old female patient and finds that the patient is breathing so shallowly that the respirations cannot be counted. What would be the appropriate initial nursing intervention in this situation?
- Notify the primary care provider.
- Perform a pain assessment.
- Administer oxygen.
- Auscultate the lung sounds and count respirations.
- Auscultate the lung sounds and count respirations.
Explanation:
If the respirations are too shallow to count it is easier to count respirations by auscultating the lung sounds. The nurse should auscultate lung sounds and count respirations for 30 seconds, then multiply by 2 to calculate the respiratory rate per minute. If the respiratory rate is irregular, the nurse should count for a full minute. The nurse notifies the physician of the respiratory rate and the shallowness of the respirations following assessment. Pain typically causes vital signs to elevate. The nurse cannot administer oxygen without a physician's order.
Chapter 24: Vital Signs - Page 615
A nurse is assessing a newborn at the healthcare facility when the mother of the child asks the nurse why the body temperature of her baby is unstable. Which response by the nurse would be most appropriate?
- "The baby is showing how it is adapting to the environmental temperature.
- "It is common for newborns to have body temperatures less than 36.4C (97.6°F)"
- "It is because of the closely woven, dark fabric wrapped around the baby"
- "It is because of the immature ability to regulate temperature in general."
Explanation:
The nurse should explain to the mother that newborns have unstable body temperatures because their thermoregulatory mechanisms are immature. It is not uncommon for an elderly person's body temperature to be less than 36.4C (97.6F) because normal temperature drops as a person ages. Newborns and infants lack the ability to decrease heat loss in response to environmental temperatures and cannot usually mount a robust fever response to infection. Changes in environmental temperatures do not affect core body temperature. Covering the body with closely woven, dark fabric helps to reduce radiant heat loss, but it is not responsible for unstable body temperatures in newborns
Chapter 24: Vital Signs - Page 583-584
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?
- Strong pulse
- Thready pulse
- Rapid pulse
- Bounding pulse
- Thready pulse
Explanation:
A feeble, weak, or thready pulse describes a pulse that is difficult to feel or, once felt, is obliterated easily with slight pressure. A normal pulse is described as strong when it can be felt with mild pressure over the artery. A pulse is considered rapid when the beats exceed 100 bpm, which is not the case here. A bounding or full pulse produces a pronounced pulsation that does not easily disappear with pressure. A strong pulse is felt with a very mild pressure over the artery.
Chapter 24: Vital Signs - Page 589
Upon assessing a patient who is hemorrhaging, the nurse is most likely to assess which compensatory change in vital signs?
- Increased pulse rate
- Decreased pulse rate
- Increased temperature
- Decreased temperature
- Increased pulse rate
Explanation:
When the stroke volume decreases, such as when blood volume is decreased because of hemorrhage, the heart rate increases to try to maintain the same cardiac output.
Chapter 24: Vital Signs - Page 588
The nurse is assessing a patient's brachial artery blood pressure. Which nursing actions are performed correctly? (Select all that apply.)
- The nurse centers the bladder of the cuff over the brachial artery about midway on the arm.
- The nurse places the cuff over the patient's bulky clothing and fastens it snugly.
- The nurse notes the point on the gauge at which the first faint but clear sound appears and increases in intensity as the diastolic pressure.
- The nurse repeats any suspicious reading before one minute has passed since the last reading.
- The nurse has the patient lying or sitting down with the forearm supported at the level of the heart and the palm of the hand upward.
- The nurse wraps the cuff around the arm smoothly and snugly and fastens it.
- The nurse centers the bladder of the cuff over the brachial artery about midway on the arm.
- The nurse has the patient lying or sitting down with the forearm supported at the level of the heart and the palm of the hand upward.
- The nurse wraps the cuff around the arm smoothly and snugly and fastens it.
- The nurse notes the point on the gauge at which the first faint but clear sound appears and increases in intensity as the diastolic pressure.
Explanation:
Pressure in the cuff applied directly to the artery provides the most accurate readings. If necessary, thick or bulky clothing is removed to allow for audible sounds of the blood pressure. BP measured with the arm below the level of the right atrium of the heart may produce a falsely high reading; if below the level of the heart the readings may be falsely too low. A smooth cuff and snug wrapping produce equal pressure and help promote an accurate measurement. A cuff wrapped too loosely results in an inaccurate reading. Placing the cuff over the patient's clothing prevents hearing the blood pressure accurately. The first faint but clear sound is the systolic pressure. False readings are likely to occur if there is congestion of blood in the limb while obtaining repeated readings that are less than 1 minute apart.
An adult pulse greater than 100 beats per minute is
- Bradycardia
- Bradypnea
- Tachycardia
- Tachypnea
- Tachycardia
Explanation:
Adult pulse rates above 100 beats per minute are termed tachycardia.
A pulse deficit is the difference between
- The systolic and diastolic blood pressure readings
- Palpated and auscultated blood pressure readings
- The radial pulse and the ulnar pulse rates
- The apical pulse and the radial pulse rate
- The apical pulse and the radial pulse rate
Explanation:
When a pulse deficit is present, the radial pulse is always lower than the apical pulse rate.
Which of the following pathologic conditions would result in release of ADH by the posterior pituitary?
- hemorrhage
- allergies
- obesity
- asthma
- hemorrhage
Explanation:
ADH is released from the posterior pituitary when stimulated by decreased blood volume and blood pressure (such as with hemorrhage) or increased osmolarity of the blood. Its effect is to retain water to increase circulatory fluid volume and, in turn, increase blood pressure. ADH release is not stimulated by allergies, obesity, or asthma.
The nursing student is selecting a blood pressure cuff prior to obtaining a patient's blood pressure. What cuff width is appropriate to obtain an accurate blood pressure reading?
- 40% of the circumference of the limb to be used
- 50% of the circumference of the limb to be used
- 60% of the circumference of the limb to be used
- 70% of the circumference of the limb to be used
- 40% of the circumference of the limb to be used
Explanation:
The width of the cuff should be about 40% of the circumference of the limb to be used.
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?
- The first appearance of faint but distinctive tapping sounds
- The last sound before there is complete and continuous silence
- The first sound that is audible after the auscultatory gap
- The transition from tapping sounds to muffled sounds
- The first appearance of faint but distinctive tapping sounds
Explanation:
The systolic blood pressure reading occurs during phase I, which is characterized by the appearance of faint but clear tapping sounds that gradually increase in intensity.
An 80-year-old client has a body temperature of 97°F. Which condition best accounts for this client's temperature reading?
-Altered endocrine function
- Hypothyroidism
- Temperature drops with age
- The client is anemic
- Temperature drops with age
Explanation:
It is not uncommon for elderly persons to have body temperatures less than 97.6° because normal temperature drops as a person ages.
A client has had a left-side mastectomy. How does this affect the blood pressure assessment?
- Assess the blood pressure in the wrist
- There is no effect on the blood pressure
- Assessment of blood pressure is impeded
- The blood pressure stays within normal range
- Assessment of blood pressure is impeded
Explanation:
If the client has had a mastectomy, blood-pressure monitoring on the same side can further impede circulation, contributing to lymphedema.
The nurse is performing a telephone follow-up with parents that she taught to monitor their newborn's BP and pulse at home. What results reported by the parents would indicate that the parents are performing the technique correctly and there is no cause for concern?
- 80/50 mm Hg and 145 bpm
- 90/50 mm Hg and 85 bpm
- 102/61 mm Hg and 75 bpm
- 120/80 mm Hg and 60 bpm
- 80/50 mm Hg and 145 bpm
Explanation:
Newborns and infants have higher heart rates and lower BP than adults. The heart rate decreases with age and the BP increases with age. The normal range for newborn heart rate is 70-190 bpm and a BP of 80/50 is acceptable. All of the other heart rates in the examples above fall below the normal range for newborns and should cause concern.
When creating the teaching plan for a client that will be monitoring his or her pulse at home, which factors should the nurse teach the client that may influence the pulse rate by causing an increase in pulse? Select all that apply.
- Aging
- Exercise
- Fever
- Male gender
- Stress
- Exercise
- Fever
- Stress
Explanation:
Some factors that may cause the pulse to increase include exercise, fever, stress, medications, and disease. Younger clients have a higher pulse rate; aging causes a decrease in pulse. Females tend to have a slightly higher pulse than males.
Which patient would the nurse consider at risk for low blood pressure?
- A patient with high blood viscosity
- A patient with low blood volume
- A patient with decreased elasticity of walls of arterioles
- A patient with a strong pumping action of blood into the arteries
- A patient with low blood volume
Explanation:
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.
Assessment of the pulse amplitude is accomplished by which of the following?
- Palpating the flow of blood through an artery
- Auscultating the area of the left ventricle
- Palpating the area of the left ventricle
- Auscultating the flow of blood through an artery
- 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.
A client monitoring his BP at home notices that his BP is higher in one arm than the other so 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.
- It has been found that most people have differences in BP between arms and that he should use the arm that gives him the lowest reading for accurate results.
- This has no impact on BP readings and he should continue doing what he has been doing.
- This is unusual and should be seen about as soon as possible.
- 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.
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.
Chapter 24: Vital Signs - Page 600
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 inch above the crease of the elbow.
- fit snug around the upper arm with room to slip a fingertip under the cuff and should be touching the crease of the elbow.
- fit snug around the upper arm with room to slip three fingertips under the cuff and should be 1 inch above the crease of the elbow.
- fit snug around the upper arm with no room to slip a fingertip under the cuff and should be 2 inches above the crease of the elbow.
- fit snug around the upper arm with room to slip a fingertip under the cuff and should be 1 inch above the crease of the elbow.
Explanation:
When teaching a client to perform home blood pressure monitoring (HBPM), he or she should be taught that the proper fitting cuff should fit snug around the upper arm with room to slip a fingertip under the cuff and should be 1 inch above the crease of the elbow
Chapter 24: Vital Signs - Page 604
The nurse is taking a rectal temperature on a patient who reports feeling light-headed during the procedure. What would be the nurse's priority action in this situation?
- Leave the thermometer in and notify the physician.
- Remove the thermometer and assess the blood pressure and heart rate.
- Remove the thermometer and assess the temperature via another method.
- Call for assistance and anticipate the need for CPR.
- Remove the thermometer and assess the blood pressure and heart rate
Explanation:
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 patient to feel light-headed; therefore the thermometer should be removed immediately and the pulse and blood pressure assessed. The physician can be called after assessing the patient. The temperature is not the priority at this time. Assistance for CPR would be determined if the patient's condition worsens.
Chapter 24: Vital Signs - Page 588-589
The nurse is teaching the parents of an infant with an irregular heartbeat how to check the pulse rate. The infant's pulse is very high and irregular. What will the nurse have to do in order to teach these parents how to monitor their infant's pulse rate?
The parents will have to be taught how to use a stethoscope so that they can listen to and count the infant's apical pulse.
If a peripheral pulse is difficult to assess accurately because it is irregular, weak, or very rapid, the apical rate should be assessed using a stethoscope.
An apical pulse is also assessed when giving medications that alter heart rate and rhythm. Apical pulse measurement is also the preferred method of pulse assessment for infants and children younger than 2 years of age. Families can be taught to use a stethoscope to check a pulse. This infant does not need a cardiac monitor, the parents should not be encouraged to get a neighbor or family friend to help, and these parents can be taught to check this infant's pulse accurately.
The nurse has completed an assessment and notes that the client's blood pressure is 132/92 mmHg. What is this client's pulse pressure?
40 mmHg
The difference between systolic blood pressure and diastolic blood pressure is called the pulse pressure; 132 − 92 = 40.
Which client's blood pressure best describes the condition called hypotension?
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 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?
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.
An older adult client monitors their blood pressure at home. Lately the client has been experiencing dizziness and nausea, followed by a headache when arising from lying down for a nap. The client was worried it was their blood pressure and began measuring their blood pressure arising from their nap. The client found that their blood pressure would drop shortly after getting. The client followed up with their health care provider and was diagnosed with orthostatic hypotension. What is the most important concern the nurse will include in the teaching plan?
falls risk related to inadequate physiologic response to postural (positional) changes.
Orthostatic hypotension (postural hypotension) is a decrease in systolic blood pressure of 20 mm Hg or a decrease in diastolic blood pressure of 10 mm Hg within 3 minutes of standing when compared with blood pressure from the sitting or supine position. It results from an inadequate physiologic response to postural (positional) changes in blood pressure. Orthostatic hypotension may be acute or chronic, as well as symptomatic or asymptomatic. It is associated with dizziness, lightheadedness, blurred vision, weakness, fatigue, nausea, palpitations, and headache. Older adult clients may experience orthostatic hypotension without associated symptoms, leading to falls.
While assessing vital signs of a client with a head injury and increased intracranial pressure (IICP), a nurse notes that the client's respiratory rate is 8 breaths/minute. How will the nurse interpret this finding?
Bradypnea is a response to IICP.
The normal respiratory rate for adults is 12 to 20 breaths/min. Bradypnea, a decrease in respiratory rate, characteristically occurs in some pathologic conditions. An increase in intracranial pressure depresses the respiratory center, resulting in slow breathing.
When administering beta blocker medications, the health care provider adds an order to hold medication when the client is bradycardic. Which statement explains this order?
The client's pulse rate is below 60 beats per minute.
An abnormally slow pulse rate is called bradycardia. In adults, a pulse rate below 60 beats per minute is considered bradycardic. The normal respiratory rate is 12 to 24 breaths per minute. A client with a systolic blood pressure less than 100 mm Hg would be hypotensive as the normal systolic blood pressure is less than 140 mm Hg. Bradycardia is not associated with a client having to sit upright when the blood pressure is checked.
While recording the pulse of an infant at 160 beats/min, the parent asks if it is normal for the infant's pulse rate to be so high. Which statement by the nurse best answers the parent's question?
"A heart rate of 160 beats/min is normal for a healthy infant."
The average pulse rate of an infant ranges from 100 to 160 beats/min. There is no need to refer the parent to the health care provider for an answer.
Which pulse site is generally used in emergency situations?
carotid
The carotid artery is lightly palpated to obtain a pulse in emergency assessments, such as in a client in shock or cardiac arrest. The brachial pulse site is used for infants who have had a cardiac arrest. The apical pulse is the fifth intercostal space for adults and the fourth intercostal space for a young child or infant. Using a stethoscope at the apex of the heart, a nurse can assess the lub dub of the heart sounds. Radial pulse is too distant to assess a pulse in an emergency assessment. Temporal pulse is difficult to assess.
The nurse is preparing to assess a rectal temperature on an adult client. What is the appropriate nursing intervention?
Provide privacy for the client.
Rectal temperature assessment can be embarrassing for the client, so provision of privacy is a priority. The client should be positioned on the side in Sims position to help facilitate probe insertion. The probe should be inserted 1 to 1.5 in (2.5 to 3.75 cm) in an adult client. The probe should only remain in the rectum until the electronic unit emits an audible sound indicating that the temperature assessment is complete.
A nurse is assessing an apical pulse on an older adult client who takes metoprolol daily. The nurse can anticipate that the client's medication will:
decrease the apical pulse.
Metoprolol is a beta-blocker that will decrease the heart rate. Beta blockers do not decrease glucose levels, respiratory rate or blood volume.
A nurse has applied a blood pressure cuff to a client's upper arm, positioned the stethoscope over the client's brachial artery, inflated the cuff and is now slowly releasing air from the cuff. The nurse should recognize the client's peak blood pressure when what sound is audible?
A faint, clear tapping sound.
Korotkoff sounds have five unique phases. Phase I begins with the first faint but clear tapping sound that follows a period of silence as pressure is released from the cuff. When the first sound occurs, it corresponds to the peak pressure in the arterial system during heart contraction, or the systolic pressure measurement. This sound does not have the two-stage sound of a heartbeat.