Deck 19: Vital Signs

Question 1

During a routine vital sign assessment, the nurse notes the client's blood pressure is 212/110. Why is this finding particularly significant?

A) It allows the nurse to have a baseline value.
B) It deviates from normal and is significant.
C) It is due to the fact the client is fearful.
D) It is related to a tumor of the adrenal gland.

Answer 1

It deviates from normal and is significant.

Question 2

The normal adult temperature obtained through the oral route ranges from:

A) 96.6°F to 98.6°F
B) 97.6°F to 99.6°F
C) 98.6°F to 100.4°F
D) 98.2°F to 100.2°F

Answer 2

97.6°F to 99.6°F

Question 3

The temperature is 102°F (39°C) during a heat wave. The nurse can expect admissions to the emergency room to present with:

A) increased temperature.
B) increased cardiac output.
C) decreased heart rate.
D) decreased respirations.

Answer 3

increased temperature.

Question 4

When assessing an infant's axillary temperature, it will be:

A) 1 degree lower than an oral temperature.
B) 1 degree higher than a rectal temperature.
C) 1 degree higher than an oral temperature.
D) the same as the tympanic temperature.

Question 5

Body temperature regulation occurs in a part of the brain known as the:

A) hypophysis
B) hypothalamus
C) pineal gland
D) thalamus

Question 6

An 80-year-old client has a body temperature of 97°F (36°C). Which condition best accounts for this client's temperature reading?

A) Altered endocrine function.
B) Hypothyroidism.
C) Temperature drops with age.
D) The client is anemic.

Question 7

Based upon circadian rhythms, when would the nurse note the highest temperature during a 24-hour period?

A) 3 am
B) 11 am
C) 3 pm
D) 5 pm

Question 8

Which client should not have a temperature assessed rectally?

A) Client with ALS
B) Client with cancer
C) Client with diarrhea
D) Client with a herniated disc

Question 9

Infants and children's pulses vary most with:

A) respirations.
B) rest.
C) eating.
D) sleep.

Question 10

A nurse is assessing an apical pulse on a client with a heart condition. The client is taking digoxin. The nurse can anticipate that the digoxin will:

A) decrease the blood glucose.
B) decrease the blood volume.
C) decrease the apical pulse.
D) decrease the respiratory rate.

Question 11

A nurse can most accurately assess a client's heart rate and rhythm by which method?

A) Listen with the stethoscope at the fifth intercostal space left midclavicular line.
B) Listen with the stethoscope at the fifth intercostal space at the sternum.
C) Listen with a stethoscope at the neck to the right of the coracoid process.
D) Listen with a stethoscope at the second intercostal space left sternum.

Question 12

An ultrasonic Doppler is used for:

A) auscultating a pulse that is difficult to palpate.
B) auscultating diastolic blood pressure.
C) aiding palpation of pulse and rhythm.
D) aiding palpation of diastolic blood pressure.

Question 13

Clients demonstrating apnea have what?

A) A temporary cessation of breathing
B) Decreased rate and depth of respirations
C) Increased rate and depth of respirations
D) Normal respiratory rate of 20

Question 14

A client has smoked most of his life and has labored respirations. He is experiencing:

A) dyspnea
B) fremitus
C) stridor
D) wheeze

Question 15

A client has had a left-side mastectomy. How does this affect the blood pressure assessment?

A) Assess the blood pressure in the wrist.
B) There is no effect on the blood pressure.
C) Assessment of blood pressure is impeded.
D) The blood pressure stays within normal range.

Question 16

The nurse is taking the apical pulse of a 6-month-old infant. Upon completion, the nurse tells the parent the baby's pulse is 140 beats per minute. The parent is concerned, stating, "That seems kind of high!" The nurse responds:

A) "Yes, this is termed tachycardia. I will let the doctor know right away."
B) "Yes, it seems fast but actually, normal infant heart rates are 150 to 200 beats per minute so it is a bit slow."
C) "I know it seems fast, but normal infant heart rates are 100 to 160 beats per minute."
D) "Yes, this is termed tachypnea. I will let the doctor know right away."

Question 17

The nurse is taking the client's temperature. The nurse understands that the rectal route is one of the most reliable. Which client can safely handle the rectal route of taking temperature?

A) A client who is short of breath just by using the restroom
B) A 9-month-old infant who has been crying for the past 2 hours
C) The 65-year-old male who just finished drinking coffee
D) The client who is vomiting

Question 18

The nurse observes the client's frequent use of the incentive spirometer. The client states "I do not want to have pneumonia while in the hospital." Which vital sign reading demonstrates effectiveness of this intervention?

A) Respiratory rate of 12 breaths per minute
B) Blood pressure of 126/84 mm Hg
C) Temperature of 98.2°F
D) Pulse rate of 100 beats per minute

Question 19

The client's blood pressure has gradually decreased in the last 2 days. Which condition would cause this change?

A) The client who has unresolved pain issues
B) The client who has been given three units of whole blood
C) The client who has had persistent diarrhea
D) The client who is to be discharged home on hospice

Question 20

Which outcome best reflects achievement of the goal, "The client will demonstrate correct steps in taking his own pulse rate"?

A) Firm placement of thumb on the inner wrist of the opposite arm
B) Palpation of the radial pulse on the thumb side of the inner aspect of the wrist
C) Light palpation of the femoral pulse below the inguinal area
D) Firm palpation of bilateral carotid artery for 1 minute

Question 21

After taking the client's postural vital signs, the student nurse determines that the client has manifested orthostatic hypotension. Which nursing diagnoses can be created? Select all that apply.

A) Alteration in rest and comfort
B) Fluid volume deficit
C) Risk for falls
D) Pain
E) Ineffective individual coping

Question 22

While assessing for orthostatic hypotension, the nurse follows which steps when taking the blood pressure? Select all that apply.

A) Check and record blood pressure taken while the client is in the bed.
B) Assist client to a sitting position with feet dangling off the floor.
C) Assist client to standing position and wait 2 minutes before taking his or her blood pressure.
D) Record measurements and report a drop of 25 mm Hg systolic and 10 mm Hg diastolic.
E) Keep the blood pressure cuff attached the whole time.