Exam 21: Measuring Vital Signs

When a frail 83-year-old patient whose temperature was 96.8° F at 8:00 AM shows a temperature of 98.6° F at 4:00 PM, the nurse is:

The nurse converts the Fahrenheit temperature of 99.2° to a Celsius reading of ______°.

The nurse would anticipate a patient diagnosed with damage to the hypothalamus after suffering a head injury from a fall to exhibit:

The nurse caring for a 30-year-old postsurgical patient would assess that the patient is in pain as indicated by:

A nurse is caring for a patient with a cardiac disease history. When measuring vital signs, the nurse finds that the radial pulse is 102 beats/min and irregular. The nurse correctly:

The nurse using either a regular or an electronic sphygmomanometer would ensure that the cuff is the correct size by:

For the nurse to assess the most accurate respiration count, the nurse should:

Regarding the blood pressure in children, the diastolic pressure is assessed by the auscultation of a:

The nurse taking an apical pulse would place the stethoscope at:

A patient who is terminally ill is described during shift report as having Cheyne-Stokes breathing. On assessment, the nurse anticipates finding:

The nurse would refrain from applying a blood pressure cuff on the affected arm of a patient who has a: (Select all that apply.)

The nurse documents vital signs on a newly admitted patient as: "blood pressure is 148/94 mm Hg, the pulse is 80 beats/min, and the respirations are 16 breaths/min." The nurse would record the pulse pressure as _____ mm Hg.

The nurse would document a patient as being febrile if the patient's temperature was over _____° F.

The nurse is caring for a patient who had a cardiac catheterization 2 hours ago and has a pressure dressing to his left groin. In addition to taking routine vital signs, the nurse should also check the:

The nurse covers a newborn baby's head with a cap, because the head:

A patient has been admitted with hypothermia after lying unconscious overnight in an unheated apartment. The most appropriate route to assess the patient's core temperature would be:

The home health nurse is instructing a caregiver about caring for a patient with hypothermia. The nurse recognizes that further instruction is warranted when the caregiver states, "I will:

Standards of the Joint Commission state that pain is the fifth vital sign and should be documented by assessments of: (Select all that apply.)

To ensure an accurate reading when using a glass oral thermometer, it is necessary to:

When caring for a victim with a gunshot wound to the abdomen who has lost a significant amount of blood, the nurse would anticipate the vital signs to reflect: