Question 1

A student is late for his appointment and has rushed across campus to the health clinic. How should the nurse proceed?

Accepted Answer

A comfortable, relaxed person yields a valid blood pressure. Many people are anxious at the beginning of an examination; the nurse should allow at least a 5-minute rest period before measuring blood pressure. Verifying the blood pressure in both arms only needs to be done once, usually with the first complete physical examination, but exercise should not cause a difference in the readings between arms. Checking the blood pressure in a supine position does not provide a more accurate reading.

Question 2

When assessing the force, or strength, of a pulse, what should the nurse recall about the pulse?

Accepted Answer

The heart pumps an amount of blood (the stroke volume) into the aorta. The force flares the arterial walls and generates a pressure wave, which is felt in the periphery as the pulse. The force of the pulse is typically recorded on a 0- to 3-point scale, not a 0- to 2-point scale. The force of the pulse does not reflect the elasticity of blood vessels' walls or the volume in the arteries during diastole.

Question 3

When assessing a patient's pulse, the nurse should also notice which of these characteristics?

Accepted Answer

The pulse is assessed for rate, rhythm, and force. Pallor, capillary refill time, and timing in the cardiac cycle are not things that should or can be assessed when assessing a patient's pulse.

Question 4

When measuring a patient's body temperature, the nurse should keep in mind that what can influence the temperature?

Accepted Answer

Normal temperature is influenced by the diurnal cycle, exercise, and age. The other responses do not influence body temperature. Constipation and patient's emotional state do not influence body temperature. Nocturnal cycle is not a real term.

Question 5

The nurse notices that a colleague is preparing to check the blood pressure of a patient who is obese by using a standard-sized blood pressure cuff. How would this likely affect the blood pressure reading?

Accepted Answer

Using a cuff that is too narrow yields a falsely high blood pressure because it takes extra pressure to compress the artery.

Question 6

What technique should the nurse use to accurately assess a rectal temperature in an adult?

Accepted Answer

A lubricated rectal thermometer (with a short, blunt tip) is inserted only 2 to 3 cm (1 inch) into the adult rectum and left in place for 2 minutes. Cigarette smoking does not alter rectal temperatures.
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Question 7

The nurse is examining a patient who is complaining of "feeling cold." Which is a mechanism of heat loss in the body?

Accepted Answer

The body maintains a steady temperature through a thermostat or feedback mechanism, which is regulated in the hypothalamus of the brain. The hypothalamus regulates heat production from metabolism, exercise, food digestion, and external factors with heat loss through radiation, evaporation of sweat, convection, and conduction.

Question 8

When evaluating the temperature of older adults, the nurse should remember which aspect about an older adult's body temperature?

Accepted Answer

In older adults, the body temperature is usually lower than in other age groups, with a mean temperature of 36.2F1F1F1S1F1F1F10 C.

Question 9

The nurse will perform a palpated pressure before auscultating blood pressure. What is the reason for this?

Accepted Answer

Inflation of the cuff 20 to 30 mm Hg beyond the point at which a palpated pulse disappears will avoid missing an auscultatory gap, which is a period when the Korotkoff sounds disappear during auscultation.

Question 10

Which of these actions illustrates the correct technique the nurse should use when assessing oral temperature with a glass thermometer?

Accepted Answer

The thermometer should be left in place 3 to 4 minutes if the person is afebrile and up to 8 minutes if the person is febrile. The nurse should wait 15 minutes if the person has just ingested hot or iced liquids and 2 minutes if he or she has just smoked. A glass thermometer should be shaken down to 35.5$\degree$ C, not 37.5$\degree$ C, before taking a patient's temperature. The thermometer should be placed at the base of the tongue, not the front. The correct answer is to leave the thermometer in place for 3 to 4 minutes if the person is afebrile and up to 8 minutes if the person is febrile.

Question 11

The nurse should measure rectal temperatures in which of these patients?

Accepted Answer

Rectal temperatures should be taken when the other routes are impractical, such as for comatose or confused people, for those in shock, or for those who cannot close the mouth because of breathing or oxygen tubes, a wired mandible, or other facial dysfunctions.

Question 12

A patient's blood pressure is 118/82 mm Hg. He asks the nurse, "What do the numbers mean?" Which is the best reply by the nurse?

Accepted Answer

The systolic pressure is the maximum pressure felt on the artery during left ventricular contraction, or systole. The diastolic pressure is the elastic recoil, or resting, pressure that the blood constantly exerts in between each contraction. The nurse should answer the patient's question and use terms he can understand. The nurse should answer the patient's question in terms they can understand and not just say it is normal and there is nothing to worry about. The diastolic pressure is the pressure in the vessels when the heart is at rest, not the stroke volume.

Question 13

The nurse is assessing the vital signs of a 3-year-old patient who appears to have an irregular respiratory pattern. How should the nurse assess this child's respirations?

Accepted Answer

Respirations are counted for 1 full minute if an abnormality is suspected. The other responses are not correct actions. The pulse and respirations should not be counted at the same time. Instead, the nurse should maintain the position as if taking the radial pulse, but unobtrusively count the respirations. Respirations should be counted for 30 seconds if no abnormality, not 5 minutes or 15 seconds. If an abnormality is suspected, the nurse should count respirations for 1 full minute.

Question 14

The nurse is assessing the vital signs of a 20-year-old male marathon runner and documents the following vital signs: temperature-36$\degree$ C; pulse-48 beats per minute; respirations-14 breaths per minute; blood pressure-104/68 mm Hg. Which statement is true concerning these results?

Accepted Answer

This is a normal finding for this patient. Although, in the adult, a heart rate less than 50 beats per minute is called bradycardia, this normally occurs in the well-trained athlete whose heart muscle develops along with the skeletal muscles. This is not tachycardia; tachycardia would be a pulse above 100 beats/minute. The patient's physician does not need to be called and the patient does not need to return in a week based on these findings. Instead, a heart rate less than 50 beats per minute in an adult is called bradycardia. However, this normally occurs in the well-trained athlete whose heart muscle develops along with the skeletal muscles.

Question 15

While measuring a patient's blood pressure, the nurse should recall that which is a factor that influences a patient's blood pressure?

Accepted Answer

The level of blood pressure is determined by five factors: cardiac output, peripheral vascular resistance, volume of circulating blood, viscosity, and elasticity of the vessel walls.

Question 16

When assessing the pulse of a 6-year-old boy, the nurse notices that his heart rate varies with his respiratory cycle, speeding up at the peak of inspiration and slowing to normal with expiration. What action should the nurse take next?

Accepted Answer

Sinus dysrhythmia is commonly found in children and young adults. During the respiratory cycle, the heart rate varies, speeding up at the peak of inspiration and slowing to normal with expiration. There is no need to notify the physician; check the child's blood pressure for variations with respirations, or documenting as bradycardia if the rate is not below 70 beats/minute.

Question 17

A nurse is helping at a health fair at a local mall. What should the nurse keep in mind when taking blood pressures on a variety of people?

Accepted Answer

In the United States, an African-American adult's blood pressure is usually higher than that of a non-Hispanic White adult of the same age. After menopause, blood pressure in women is higher than in men; blood pressure measurements in people who are obese are usually higher than in those who are not overweight. Normally, a gradual rise occurs through childhood and into the adult years. After menopause, blood pressure in women is higher than in men; blood pressure measurements in people who are obese are usually higher than in those who are not overweight; and there is normally a gradual increase in blood pressure through childhood and into the adult years. The incidence of hypertension is twice as high in African-Americans as it is in non-Hispanic Whites.

Question 18

Which technique is correct when the nurse is assessing the radial pulse of a patient?

Accepted Answer

Research suggests that the 30-second interval multiplied by 2 is a more accurate and efficient technique when heart rates are normal or rapid and when rhythms are regular, then the 15-seconds interval multiplied by 4 as any one beat error in counting results in an error of 4 beats/minute. If the rhythm is irregular, then the pulse is counted for 1 full minute.

Question 19

The nurse is teaching a student nurse about the different types of thermometers. When teaching the student about the advantages of the tympanic membrane thermometer (TMT), which statement should the nurse include?

Accepted Answer

The TMT is useful for young children who may not cooperate for oral temperatures and fear rectal temperatures. However, the use of a TMT with newborn infants and young children is conflicting.

Question 20

When assessing an older adult, the nurse should recognize that which vital sign changes occur with aging?

Accepted Answer

With aging, the nurse keeps in mind that the systolic blood pressure increases, leading to widened pulse pressure. With many older people, both the systolic and diastolic pressures increase. The pulse rate and temperature do not increase with aging. However, both the systolic and diastolic pressures increase in many older adults.

Quiz 10: Vital Signs

A student is late for his appointment and has rushed across campus to the health clinic. How should the nurse proceed?

When assessing the force, or strength, of a pulse, what should the nurse recall about the pulse?

When assessing a patient's pulse, the nurse should also notice which of these characteristics?

When measuring a patient's body temperature, the nurse should keep in mind that what can influence the temperature?

The nurse notices that a colleague is preparing to check the blood pressure of a patient who is obese by using a standard-sized blood pressure cuff. How would this likely affect the blood pressure reading?

What technique should the nurse use to accurately assess a rectal temperature in an adult?

The nurse is examining a patient who is complaining of "feeling cold." Which is a mechanism of heat loss in the body?

When evaluating the temperature of older adults, the nurse should remember which aspect about an older adult's body temperature?

The nurse will perform a palpated pressure before auscultating blood pressure. What is the reason for this?

Which of these actions illustrates the correct technique the nurse should use when assessing oral temperature with a glass thermometer?

The nurse should measure rectal temperatures in which of these patients?

A patient's blood pressure is 118/82 mm Hg. He asks the nurse, "What do the numbers mean?" Which is the best reply by the nurse?

The nurse is assessing the vital signs of a 3-year-old patient who appears to have an irregular respiratory pattern. How should the nurse assess this child's respirations?

The nurse is assessing the vital signs of a 20-year-old male marathon runner and documents the following vital signs: temperature-36 $\degree$ C; pulse-48 beats per minute; respirations-14 breaths per minute; blood pressure-104/68 mm Hg. Which statement is true concerning these results?

While measuring a patient's blood pressure, the nurse should recall that which is a factor that influences a patient's blood pressure?

When assessing the pulse of a 6-year-old boy, the nurse notices that his heart rate varies with his respiratory cycle, speeding up at the peak of inspiration and slowing to normal with expiration. What action should the nurse take next?

A nurse is helping at a health fair at a local mall. What should the nurse keep in mind when taking blood pressures on a variety of people?

Which technique is correct when the nurse is assessing the radial pulse of a patient?

The nurse is teaching a student nurse about the different types of thermometers. When teaching the student about the advantages of the tympanic membrane thermometer (TMT) , which statement should the nurse include?

When assessing an older adult, the nurse should recognize that which vital sign changes occur with aging?

Quiz 10: Vital Signs

A student is late for his appointment and has rushed across campus to the health clinic. How should the nurse proceed?

When assessing the force, or strength, of a pulse, what should the nurse recall about the pulse?

When assessing a patient's pulse, the nurse should also notice which of these characteristics?

When measuring a patient's body temperature, the nurse should keep in mind that what can influence the temperature?

The nurse notices that a colleague is preparing to check the blood pressure of a patient who is obese by using a standard-sized blood pressure cuff. How would this likely affect the blood pressure reading?

What technique should the nurse use to accurately assess a rectal temperature in an adult?

The nurse is examining a patient who is complaining of "feeling cold." Which is a mechanism of heat loss in the body?

When evaluating the temperature of older adults, the nurse should remember which aspect about an older adult's body temperature?

The nurse will perform a palpated pressure before auscultating blood pressure. What is the reason for this?

Which of these actions illustrates the correct technique the nurse should use when assessing oral temperature with a glass thermometer?

The nurse should measure rectal temperatures in which of these patients?

A patient's blood pressure is 118/82 mm Hg. He asks the nurse, "What do the numbers mean?" Which is the best reply by the nurse?

The nurse is assessing the vital signs of a 3-year-old patient who appears to have an irregular respiratory pattern. How should the nurse assess this child's respirations?

The nurse is assessing the vital signs of a 20-year-old male marathon runner and documents the following vital signs: temperature-36 °\degree° C; pulse-48 beats per minute; respirations-14 breaths per minute; blood pressure-104/68 mm Hg. Which statement is true concerning these results?

While measuring a patient's blood pressure, the nurse should recall that which is a factor that influences a patient's blood pressure?

When assessing the pulse of a 6-year-old boy, the nurse notices that his heart rate varies with his respiratory cycle, speeding up at the peak of inspiration and slowing to normal with expiration. What action should the nurse take next?

A nurse is helping at a health fair at a local mall. What should the nurse keep in mind when taking blood pressures on a variety of people?

Which technique is correct when the nurse is assessing the radial pulse of a patient?

The nurse is teaching a student nurse about the different types of thermometers. When teaching the student about the advantages of the tympanic membrane thermometer (TMT) , which statement should the nurse include?

When assessing an older adult, the nurse should recognize that which vital sign changes occur with aging?

The nurse is assessing the vital signs of a 20-year-old male marathon runner and documents the following vital signs: temperature-36 $\degree$ C; pulse-48 beats per minute; respirations-14 breaths per minute; blood pressure-104/68 mm Hg. Which statement is true concerning these results?