Chapter 25: Vital Signs PrepU, Questions and answers. 2022/2023 update

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Chapter 25: Vital Signs PrepU, Questions and answers. 2022/2023 update An 80-year-old client has a body temperature of 97°F (36°C). Which condition best accounts for this client's temperature r... eading? -hypothyroidism -advanced age -altered endocrine -function anemia - ✔✔advanced age It is common for older adults to have body temperatures less than 97°F (36°C), because normal temperature drops as a person ages. The nurse is preparing to assess a client's oral temperature. The nurse should plan to place the thermometer probe in which area of the client's mouth? -deep in the posterior sublingual pocket -superior to the tongue, with the tip touching the hard palate -along either upper gum line, adjacent to an incisor -in the inferior buccal space on either side of the tongue - ✔✔deep in the posterior sublingual pocket When the probe rests deep in the posterior sublingual pocket, it is in contact with blood vessels lying close to the surface. None of the other areas provides as much contact with blood vessels and therefore is not an appropriate location to place the thermometer probe. 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: "Yes, this is termed tachypnea. I will let the doctor know right away." "Yes, it seems fast but actually, normal infant heart rates are 150-200 beats per minute so it is a bit slow." "I know it seems fast, but normal infant heart rates are 100-160 beats per minute." "Yes, this is termed tachycardia. I will let the doctor know right away." - ✔✔"I know it seems fast, but normal infant heart rates are 100-160 beats per minute." The average pulse rate of an infant ranges from 100 to 160 beats per minute. The nurse is taking a rectal temperature on a client who reports feeling lightheaded during the procedure. What would be the nurse's priority action in this situation? Remove the thermometer and assess the blood pressure and heart rate. Call for assistance and anticipate the need for CPR. Remove the thermometer and assess the temperature via another method. Leave the thermometer in and notify the physician. - ✔✔Remove the thermometer and assess the blood pressure and heart rate. 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 client to feel lightheaded; therefore, the thermometer should be removed immediately and the pulse and blood pressure assessed. The physician can be called after assessing the client. The temperature is not the priority at this time. Assistance for CPR would be determined if the client's condition worsens. Which client's blood pressure best describes the condition called hypotension? -The systolic reading is above 110 and diastolic reading is above 80. -The systolic reading is below 120 and the diastolic reading is below 80. -The systolic reading is below 100 and diastolic reading is below 60. -The systolic reading is above 102 and diastolic reading is above 60. - ✔✔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. The student nurse is having difficulty feeling the pedal pulse of the client with a fractured leg. What should the nurse do next? -Ask another student nurse to check it for him. -Connect the client to the oxygen saturation monitoring device. -Use the Doppler ultrasound device. -Use the Bell side of the stethoscope to listen. - ✔✔Use the Doppler ultrasound device. Peripheral pulses that cannot be detected by palpation may be assessed with an ultrasonic Doppler device. A conductive gel is first applied to the skin to reduce resistance to sound transmission. The transmitter of the device is then placed over the artery to be assessed. High-frequency waves directed at the artery from the transmitter are disturbed by the pulsating flow of blood and are reflected back to the ultrasound device. The sound disturbances (Doppler shifts) are amplified and heard through earpieces or a speaker attached to the device. The bell effect is created by light pressure on the stethoscope. Using the bell will not facilitate palpation but an auditory assessment. The nursing student should be familiar with other assessment devices such as the Doppler and not asking another nursing student to assess. Connecting the client to the oxygen saturation device does not assist in the assessment of pedal pulses. A client has an axillary temperature of 102.6 F (39.2°C). Which clinical manifestations would the nurse anticipate? Select all that apply. -headache -red or flushed skin -hunger -cold, clammy skin -respiratory rate 30/min - ✔✔-respiratory rate 30/min -headache -red or flushed skin The following are clinical signs associated with a fever: pinkish or red skin (skin that is warm to the touch), headache, and above-normal pulse or respiratory rates. Clients who are febrile may or may not be hungry. Clients who are febrile have warm, not cold and clammy, skin. The registered nurse is collaborating in the care of several medical clients. Which tasks may the nurse safely delegate to unlicensed assistive personnel (UAP)? Select all that apply. -Assessment of a client's axillary temperature -Assessment of a client's radial pulse -Assessment of body temperature for an infant in a radiant warmer -Palpation of a stable client's apical pulse -Auscultation of a client's apical heart rate - ✔✔-Assessment of a client's axillary temperature -Assessment of a client's radial pulse Assessment of axillary temperature and radial pulse can normally be delegated to UAP. Assessment of apical heart rate and assessment of body temperature for an infant in a radiant warmer are beyond the scope of UAP. 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? -Document the findings. -Assess the apical pulse. -Assess the carotid pulse. -Get another nurse for validation. - ✔✔Assess the apical pulse. If a radial pulse is difficult to assess accurately because it is irregular, feeble, or extremely rapid, the nurse would need to assess the apical pulse rate. By assessing the apical rate the nurse can hear the rate instead of trying to feel the rate. Assessing the carotid pulse would also be done through touch, so the outcome would be the same and not accurate. If the nurse is concerned about the client, it does not hurt to have another nurse check the pulse, but the nurse should assess the apical pulse first. The findings should be documented, but only after all assessments have been completed. When assessing a client's respiratory rate, the nurse should take which action? -Ask the client to breathe deeply. -Count the number of respirations for 10 seconds. -Do it immediately after the pulse assessment so the client is unaware of it. -Remind the client to breathe normally. - ✔✔Do it immediately after the pulse assessment so the client is unaware of it. Move immediately from the pulse assessment to counting the respiratory rate to avoid letting the client know the nurse is counting respirations. Clients should be unaware of the respiratory assessment because, if they are conscious of the procedure, they might alter their breathing patterns or rate. Thus, the nurse should not tell the client to breathe normally or deeply. Using a watch with a second hand, count the number of respirations for 30 seconds. Multiply this number by 2 to calculate the respiratory rate per minute. 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 health problem should the nurse consider when client falls occur? -secondary hypertension -primary hypertension -orthostatic hypotension -dyspnea - ✔✔orthostatic hypotension Orthostatic hypotension is associated with weakness or fainting when one rises to an erect position. Hypertension and dyspnea do not typically result in loss of balance and/or consciousness. Dyspnea is difficult or labored breathing. Essential or primary hypertension is high blood pressure. Secondary hypertension (secondary high blood pressure) is high blood pressure that's caused by another medical condition. A nurse needs to measure the blood pressure of a client who has just undergone a bilateral mastectomy. How should the nurse measure the blood pressure? -Brachial artery -Over the lower arm -Radial artery -Over the client's thigh - ✔✔Over the client's thigh The nurse should measure the blood pressure over the client's thigh or the popliteal artery behind the knee. It is inadvisable following a mastectomy to assess blood pressure at the normal site, which is over the brachial artery at the inner aspect of the elbow. In normal cases, the blood pressure may also be assessed at the lower arm and radial artery. 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? -Not to worry and to take double the dose of BP medication -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. -To call her health care provider -To take the medication that she missed and retake her BP - ✔✔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. HBPM readings are the ideal method for monitoring response to treatment for high BP. This client's average BP after not taking her medication is 138/87 and is not 10 more than what her HBPM reading has been. Clients should be taught when performing HBPM that they should call the health care provider if the averages of HBPM readings increase/decrease by 10, or if she has any concerns. The client should not be told to take double the dose of medication or to take the doses she missed; this is unsafe advice without consulting a health care provider. The nurse is assessing the client's blood pressure (BP) and heart rate (HR) for orthostatic hypotension. In which step should this nurse intervene because of potential danger? -After 3 minutes of sitting, BP 100/50; HR 90. -Client sitting at edge of bed, feet dangling for 3 minutes; asymptomatic -Client stands at bedside, becomes pale, diaphoretic. -Client in supine position for 3 minutes and BP 120/70; HR 70; asymptomati - ✔✔Client stands at bedside, becomes pale, diaphoretic. Orthostatic hypotension is assessed in three positions, with the client resting in each position 3 minutes before measuring the blood pressure and heart rate. The client is positive for orthostatic hypotension when there is a decrease of 20 mm Hg BP or greater and the heart rate increases as the body's means to help compensate for the postural change. In this case, it is part of the assessment to leave the client in the supine position for 3 minutes; the BP and HR are within a normal range and the client is asymptomatic so the nurse would not intervene. The nurse need not intervene while the client is dangling at the bedside and is asymptomatic. After 3 minutes of sitting, there was a positive orthostatic change, but the client is not exhibiting symptoms, so the nurse would finish the assessment by standing the client at the bedside to determine the extent of the postural changes. The nurse would intervene because the client is exhibiting symptoms of low cardiac output: pallor and diaphoresis. The nurse would immediately place the client in a supine position to increase the BP and report the findings to the primary care provider so adjustments in treatment may be made. A nurse is assessing the blood pressure of a client using the Korotkoff sound 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. -There is a nonauscultatory gap. -There is a widening in the diameter of the artery. -There is an adult diastolic pressure. - ✔✔There is an auscultatory gap. An auscultatory gap is a period during which sound disappears. An auscultatory gap can range as much as 40 mmHg. A widening in the diameter of the artery takes place in the phase II of the Korotkoff sound technique. An adult diastolic pressure takes place in the phase IV of the Korotkoff sound technique. A nurse is assessing the pulse volume of a client with influenza. The nurse notes that the client has a thready pulse. Which of the following is a description of a thready pulse? -Pulse is felt with difficulty and disappears with slight pressure. -Pulse is felt easily, and moderate pressure causes it to disappear. -Pulse is strong and remains strong despite moderate pressure. -Pulse is strong, and light pressure causes it to disappear. - ✔✔Pulse is felt with difficulty and disappears with slight pressure. A thready pulse is felt with difficulty or not easily felt, and slight pressure causes it to disappear. A weak pulse is stronger than a thready pulse, and light pressure causes it to disappear. A normal pulse is felt easily, and moderate pressure causes it to disappear. A bounding pulse is strong and does not disappear with moderate pressure. A nurse is assessing the respiratory rate of a sleeping 28-day-old infant. What would the nurse document as a normal finding? -12 to 20 breaths/min -30 to 60 breaths/min -60 to 80 breaths/min -80 to 100 breaths/min - ✔✔30 to 60 breaths/min When assessing the respiratory rate of an infant less than 1 month of age, the nurse knows that the normal respiratory rate of an infant at rest is approximately 30 to 60 breaths/min. The normal respiratory rate of an adult is 12 to 20 breaths/min. A respiratory rate of 60 to 80 breaths/min or 80 to 100 breaths/min is abnormal and is not seen in infants or [Show More]

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