Deck 24: Vital Signs

Question 1

What population is at greatest risk for hypertension?

A) Hispanic
B) White
C) Asian
D) African American

Answer 1

African American

Question 2

A student is reading the medical record of an assigned client and notes the client has been afebrile for the past 12 hours. What does the term "afebrile" indicate?

A) Normal body temperature
B) Decreased body temperature
C) Increased body temperature
D) Fluctuating body temperature

Answer 2

Normal body temperature

Question 3

A nurse is conducting a health history for a client with a chronic respiratory problem. What question might the nurse ask to assess for orthopnea?

A) "Do you have problems breathing when you walk up stairs?"
B) "Does your medication help you breathe better?"
C) "How many pillows do you sleep on at night to breathe better?"
D) "Tell me about your breathing difficulties since you stopped smoking."

Answer 3

"How many pillows do you sleep on at night to breathe better?"

Question 4

An male client 86 years of age with a diagnosis of vascular dementia and cardiomyopathy is exhibiting signs and symptoms of pneumonia. The nurse has attempted to assess his temperature using an oral thermometer, but the client is unable to follow directions to close his mouth and secure the thermometer sublingually. Additionally, he repeatedly withdraws his head when the nurse attempts to use a tympanic thermometer. How should the nurse proceed with this assessment?

A) Assess the client's temperature by axilla.
B) Assess the client's skin tone and the presence or absence of sweating to determine whether the client is febrile.
C) Use a disposable mercury thermometer to take the client's temperature.
D) Take the client's temperature rectally.

Question 5

Upon auscultation of a client's heart rate, the nurse notes the rate to have an irregular pattern of 72 beats/minute. The nurse notifies the physician because the client is exhibiting signs of which of the following?

A) A dysrhythmia
B) Tachycardia
C) Bradycardia
D) Hypertension

Question 6

Which is the primary source of heat in the body?

A) Hormones
B) Metabolism
C) Blood circulation
D) Muscles

Question 7

A nurse is taking a client's temperature and wants the most accurate measurement, based on core body temperature. What site should be used?

A) Rectal
B) Oral
C) Axillary
D) Forehead

Question 8

A nurse is assessing a client who has a fever, has an infection of a flank incision, and is in severe pain. What type of pulse rate would be likely?

A) Bradycardia
B) Tachycardia
C) Dysrhythmia
D) Bigeminal

Question 9

Which of the following clients should the nurse monitor vital signs every four hours?

A) A client in a critical care unit
B) A client hospitalized for high blood pressure
C) a resident in a long-term care facility
D) a long-term care resident on Medicare A

Question 10

The nurse notes a difference in systolic blood pressure readings between the client's arms. How will the nurse approach subsequent readings based upon this difference in blood pressures?

A) The nurse will use the arm with the highest reading.
B) The nurse will use the arm with the lowest reading.
C) The nurse will average the two blood pressures and document this average.
D) The nurse will obtain a blood pressure on the client's leg.

Question 11

A nurse educator is teaching a client about a healthy diet. What information would be included to reduce the risk of hypertension?

A) "Eat a diet high in fruits and vegetables."
B) "Remember to drink eight to 10 glasses of water a day."
C) "It is important to have increased fats in your diet."
D) "Put away the salt shaker and eat low-salt foods."

Question 12

What site for taking body temperature with a glass thermometer is contraindicated in clients who are unconscious?

A) Rectal
B) Tympanic
C) Oral
D) Axillary

Question 13

A client is constipated and trying to have a bowel movement. How does holding the breath and pushing down (the Valsalva maneuver) affect the pulse?

A) Left ventricle pumps more forcefully; pulse is stronger
B) Stimulates the vagus nerve to increase the rate
C) Stimulates the vagus nerve to decrease the rate
D) Right ventricle is less efficient; pulse is thready

Question 14

The arterial blood gases for a client in shock demonstrate increased carbon dioxide and decreased oxygen. What type of respirations would the nurse expect to assess based on these findings?

A) Absent and infrequent
B) Shallow and slow
C) Rapid and deep
D) Noisy and difficult

Question 15

When assessing a client's vital signs, a nursing student has explained each of her next actions prior to assessing the client's temperature, pulse, and blood pressure. However, the nurse has not announced her intention to assess the client's respiratory rate prior to measuring it. Which of the following is a plausible rationale for the nurse's decision?

A) Respirations have both autonomic and voluntary control.
B) The nurse likely assessed the client's respiratory rate simultaneous to heart rate.
C) Temperature, pulse, and blood pressure are more volatile than respiratory rate.
D) Tachypnea is an expected finding among hospitalized individuals.

Question 16

A middle-aged, overweight adult man has had hypertension for 15 years. What pathologic event is he most at risk for?

A) Stroke
B) Anemia
C) Cancer
D) Infection

Question 17

A nurse places a fan in the room of a client who is overheated. This is an example of heat loss related to which of the following mechanisms of heat transfer?

A) Evaporation
B) Radiation
C) Conduction
D) Convection

Question 18

What anatomic site regulates the pulse rate and force?

A) Thermoregulatory center
B) Cardiac sinoatrial node
C) Cardiac atria and valves
D) Peripheral chemoreceptors

Question 19

A nurse is caring for a client who is ambulating for the first time after surgery. Upon standing, the client complains of dizziness and faintness. The client's blood pressure is 90/50. What is the name for this condition?

A) Orthostatic hypotension
B) Orthostatic hypertension
C) Ambulatory bradycardia
D) Ambulatory tachycardia

Question 20

Which of the following is an average normal temperature in Centigrade for a healthy adult?

A) oral: 37.0°C
B) rectal: 36.5°C
C) axillary: 37.5°C
D) tympanic: 34.4°C

Question 21

All of the following clients have a body temperature of 38°C (100.4°F). About which client would a nurse be most concerned?

A) An older adult
B) A pregnant adolescent
C) A junior high football player
D) An infant 2 months of age

Question 22

A client in a physician's office has a single blood pressure (BP) reading of 150/92. Should the client be taught about hypertension?

A) It depends on the time of day the BP was taken.
B) It depends on whether the client is male or female.
C) No, a single BP reading should not be used.
D) Yes, this reading is high enough to be significant.

Question 23

A nurse needs to measure the pulse of a client admitted to the health care facility. Which site would the nurse most likely use?

A) Femoral
B) Temporal
C) Pedal
D) Radial

Question 24

Various sounds are heard when assessing a blood pressure. What does the first sound heard through the stethoscope represent?

A) Systolic pressure
B) Diastolic pressure
C) Auscultatory gap
D) Pulse pressure

Question 25

Two nurses collaborate in assessing an apical-radial pulse on a client. The pulse deficit is 16 beats/minute. What does this indicate?

A) The radial pulse is more rapid than the apical pulse.
B) This is a normal finding and should be ignored.
C) The client's arteries are very compliant.
D) Not all of the heartbeats are reaching the periphery.

Question 26

A nurse walks into a client's room and finds him having difficulty breathing and complaining of chest pain. He has bradycardia and hypotension. What should the nurse do next?

A) Take vital signs again in 15 to 30 minutes.
B) Document the data and report it later.
C) Ask the client if he is anxious or afraid.
D) Report findings to the physician immediately.

Question 27

A home health care nurse notices that his assigned client uses a mercury thermometer. He asks the nurse what to do if it breaks. Which of the following is not correct?

A) "Just flush the glass and mercury down the toilet."
B) "Do not vacuum the area where it breaks."
C) "Open the windows and close off the room for an hour."
D) "Throw away any clothing exposed to the mercury."

Question 28

As adults age, the walls of their arterioles become less elastic, increasing resistance and decreasing compliance. How does this affect the blood pressure?

A) The blood pressure does not change.
B) The blood pressure is erratic.
C) The blood pressure decreases.
D) The blood pressure increases.

Question 29

An adult client is assessed as having an apical pulse of 140. How would the nurse document this finding?

A) Bradycardia
B) Tachycardia
C) Dysrhythmia
D) Normal pulse

Question 30

A nurse has an order to take the core temperature of a client. At which of the following sites would a core body temperature be measured?

A) Rectal
B) Oral
C) Skin surface
D) Axillary

Question 31

The nurse at the beginning of the shift plans to see which client first, based on the following vital signs?

A) The client age 2 years whose respiratory rate is 16 breaths/minute
B) The newborn whose axillary temperature is 98.2 ºF (36.8 ºC)
C) The client age 7 years whose pulse is 120 beats/minute
D) The client age 10 years whose blood pressure is 102/62 mmHg

Question 32

A nurse is caring for a middle-aged client who looks worried and flares his nostrils when breathing. The client complains of difficulty in breathing, even when he walks to the bathroom. Which of the following breathing disorders is most appropriate to describe the client's condition?

A) Hyperventilation
B) Hypoventilation
C) Dyspnea
D) Apnea

Question 33

A hospital unit has a policy that rectal temperatures may not be taken on clients who have had cardiac surgery. What rationale supports this policy?

A) It is an embarrassing and painful assessment.
B) Thermometer insertion stimulates the vagus nerve.
C) It is less expensive to take oral temperatures.
D) It is to avoid perforating the wall of the rectum.

Question 34

A nurse palpates the pulse of a client and documents the following: 6/6/12 pulse 85 and regular, 3+, and equal in radial, popliteal, and dorsalis pedis. What does the number 3+ represent?

A) Pulse rate
B) Pulse quality (amplitude)
C) Pulse rhythm
D) Pulse deficit

Question 35

A nurse is assessing the blood pressure on an obese woman. What error might occur if the cuff used is too narrow?

A) Reading is erroneously high
B) Reading is erroneously low
C) Pressure on the cuff with be painful
D) It will be difficult to pump up the bladder