Chapter 24 Vital Signs

Chapter 24  Vital Signs

Complete Chapter Questions And Answers
 

Sample Questions

1.
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
Ans:
A

Feedback:

An irregular pattern of heartbeats is called a dysrhythmia. Tachycardia is an increased heart rate of 100 to 180 beats/minute. Bradycardia is a pulse rate below 60 beats/minute. The normal pulse rate ranges from 60 to 100 beats per minute. Hypertension is a blood pressure that is above normal for a sustained period.

2.
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.
Ans:
A

Feedback:

An initial nursing assessment should include blood pressure assessments on both arms. It is normal to have a 5- to 10-mm Hg difference in the systolic reading between arms. Use the arm with the higher reading for subsequent pressures.

3.
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.
Ans:
A

Feedback:

The axillary site is an accurate and acceptable alternative when other sites are impractical or contraindicated. Rectal temperatures are contraindicated in cardiac clients; mercury thermometers are not commonly used. It is unacceptable for the nurse to rely solely on subjective assessments to determine whether the client is febrile.

4.
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.
Ans:
A

Feedback:

Because respiratory rate is under both autonomic and voluntary control, making the client conscious of his or her respiratory rate prior to assessment has the potential to affect that accuracy of the assessment. It is not possible to simultaneously assess pulse and respirations. Temperature, pulse, and blood pressure are not necessarily more volatile than respiratory rate. Tachypnea is not an expected finding.

5.
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
Ans:
B

Feedback:

Vital signs are assessed at least every four hours in hospitalized clients with elevated temperatures, with high or low blood pressures, with changes in pulse rate or rhythm, or with respiratory difficulty. In critical care settings, technologically advanced devices are used to continually monitor clients’ vital signs. Regulations require monthly vital sign measurements in long-term care residents, but if the resident is classified as Medicare A (meaning discharged from the hospital and Medicare is paying for the stay to receive skilled nursing care) vital signs are taken daily.