Question 1

A patient's blood pressure is 118/82 mm Hg. He asks the nurse, "What do the numbers mean?" Which is the best reply by the nurse?

Accepted Answer

A)  "The numbers are within the normal range and are nothing to worry about." 
B)  "The bottom number is the diastolic pressure and reflects the stroke volume of the heart." 
C)  "The top number is the systolic blood pressure and reflects the pressure of the blood against the arteries when the heart contracts." 
D)  "The concept of blood pressure is difficult to understand. The primary thing to be concerned about is the top number, or the systolic blood pressure." 
A)  "The numbers are within the normal range and are nothing to worry about." 
B)  "The bottom number is the diastolic pressure and reflects the stroke volume of the heart." 
C)  "The top number is the systolic blood pressure and reflects the pressure of the blood against the arteries when the heart contracts." 
D)  "The concept of blood pressure is difficult to understand. The primary thing to be concerned about is the top number, or the systolic blood pressure."

Question 2

What type of blood pressure measurement error is most likely to occur if the nurse does not check for the presence of an auscultatory gap?

Accepted Answer

A)  Diastolic blood pressure may not be heard. 
B)  Diastolic blood pressure may be falsely low. 
C)  Systolic blood pressure may be falsely low. 
D)  Systolic blood pressure may be falsely high. 
A)  Diastolic blood pressure may not be heard. 
B)  Diastolic blood pressure may be falsely low. 
C)  Systolic blood pressure may be falsely low. 
D)  Systolic blood pressure may be falsely high.

Question 3

The nurse is counting an infant's respirations. Which technique is correct?

Accepted Answer

A)  Watching the chest rise and fall 
B)  Observing the movement of the abdomen 
C)  Placing a hand across the infant's chest 
D)  Using a stethoscope to listen to the breath sounds 
A)  Watching the chest rise and fall 
B)  Observing the movement of the abdomen 
C)  Placing a hand across the infant's chest 
D)  Using a stethoscope to listen to the breath sounds

Question 4

The nurse is examining a patient who is complaining of "feeling cold." Which is a mechanism of heat loss in the body?

Accepted Answer

A)  Exercise 
B)  Radiation 
C)  Metabolism 
D)  Food digestion 
A)  Exercise 
B)  Radiation 
C)  Metabolism 
D)  Food digestion

Question 5

A 4-month-old child is at the clinic for a well-baby checkup and immunizations. Which of these actions is most appropriate when the nurse is assessing an infant's vital signs?

Accepted Answer

A)  The infant's radial pulse should be palpated, and the nurse should notice any fluctuations resulting from activity or exercise. 
B)  The nurse should auscultate an apical rate for 1 minute and then assess for any normal irregularities, such as sinus dysrhythmia. 
C)  The infant's blood pressure should be assessed by using a stethoscope with a large diaphragm piece to hear the soft muffled Korotkoff sounds. 
D)  The infant's chest should be observed and the respiratory rate counted for 1 minute; the respiratory pattern may vary significantly. 
A)  The infant's radial pulse should be palpated, and the nurse should notice any fluctuations resulting from activity or exercise. 
B)  The nurse should auscultate an apical rate for 1 minute and then assess for any normal irregularities, such as sinus dysrhythmia. 
C)  The infant's blood pressure should be assessed by using a stethoscope with a large diaphragm piece to hear the soft muffled Korotkoff sounds. 
D)  The infant's chest should be observed and the respiratory rate counted for 1 minute; the respiratory pattern may vary significantly.

Question 6

The nurse is preparing to measure the vital signs of a 6-month-old infant. Which action by the nurse is correct?

Accepted Answer

A)  Respirations are measured; then pulse and temperature. 
B)  Vital signs should be measured more frequently than in an adult. 
C)  Procedures are explained to the parent, and the infant is encouraged to handle the equipment. 
D)  The nurse should first perform the physical examination to allow the infant to become more familiar with her and then measure the infant's vital signs. 
A)  Respirations are measured; then pulse and temperature. 
B)  Vital signs should be measured more frequently than in an adult. 
C)  Procedures are explained to the parent, and the infant is encouraged to handle the equipment. 
D)  The nurse should first perform the physical examination to allow the infant to become more familiar with her and then measure the infant's vital signs.

Question 7

The nurse is conducting a health fair for older adults. Which statement is true regarding vital sign measurements in aging adults?

Accepted Answer

A)  The pulse is more difficult to palpate because of the stiffness of the blood vessels. 
B)  An increased respiratory rate and a shallower inspiratory phase are expected findings. 
C)  A decreased pulse pressure occurs from changes in the systolic and diastolic blood pressures. 
D)  Changes in the body's temperature regulatory mechanism leave the older person more likely to develop a fever. 
A)  The pulse is more difficult to palpate because of the stiffness of the blood vessels. 
B)  An increased respiratory rate and a shallower inspiratory phase are expected findings. 
C)  A decreased pulse pressure occurs from changes in the systolic and diastolic blood pressures. 
D)  Changes in the body's temperature regulatory mechanism leave the older person more likely to develop a fever.

Question 8

A 70-year-old man has a blood pressure of 150/90 mm Hg in a lying position, 130/80 mm Hg in a sitting position, and 100/60 mm Hg in a standing position. How should the nurse evaluate these findings?

Accepted Answer

A)  These readings are a normal response and attributable to changes in the patient's position. 
B)  The change in blood pressure readings is called orthostatic hypotension. 
C)  The blood pressure reading in the lying position is within normal limits. 
D)  The change in blood pressure readings is considered within normal limits for the patient's age. 
A)  These readings are a normal response and attributable to changes in the patient's position. 
B)  The change in blood pressure readings is called orthostatic hypotension. 
C)  The blood pressure reading in the lying position is within normal limits. 
D)  The change in blood pressure readings is considered within normal limits for the patient's age.

Question 9

A student is late for his appointment and has rushed across campus to the health clinic. How should the nurse proceed?

Accepted Answer

A)  Allow 5 minutes for him to relax and rest before checking his vital signs. 
B)  Check the blood pressure in both arms, expecting a difference in the readings because of his recent exercise. 
C)  Immediately monitor his vital signs on his arrival at the clinic and then 5 minutes later, recording any differences. 
D)  Check his blood pressure in the supine position, which will provide a more accurate reading and will allow him to relax at the same time. 
A)  Allow 5 minutes for him to relax and rest before checking his vital signs. 
B)  Check the blood pressure in both arms, expecting a difference in the readings because of his recent exercise. 
C)  Immediately monitor his vital signs on his arrival at the clinic and then 5 minutes later, recording any differences. 
D)  Check his blood pressure in the supine position, which will provide a more accurate reading and will allow him to relax at the same time.

Question 10

When assessing the pulse of a 6-year-old boy, the nurse notices that his heart rate varies with his respiratory cycle, speeding up at the peak of inspiration and slowing to normal with expiration. What action should the nurse take next?

Accepted Answer

A)  Notify the physician. 
B)  Record this finding as normal. 
C)  Check the child's blood pressure and note any variation with respiration. 
D)  Document that this child has bradycardia and continue with the assessment. 
A)  Notify the physician. 
B)  Record this finding as normal. 
C)  Check the child's blood pressure and note any variation with respiration. 
D)  Document that this child has bradycardia and continue with the assessment.

Question 11

A nurse is helping at a health fair at a local mall. What should the nurse keep in mind when taking blood pressures on a variety of people?

Accepted Answer

A)  After menopause, blood pressure readings in women are usually lower than those taken in men. 
B)  The blood pressure of an African-American adult is usually higher than that of a non-Hispanic White adult of the same age. 
C)  Blood pressure measurements in people who are overweight should be the same as those of people who are at a normal weight. 
D)  A teenager's blood pressure reading will be lower than that of an adult. 
A)  After menopause, blood pressure readings in women are usually lower than those taken in men. 
B)  The blood pressure of an African-American adult is usually higher than that of a non-Hispanic White adult of the same age. 
C)  Blood pressure measurements in people who are overweight should be the same as those of people who are at a normal weight. 
D)  A teenager's blood pressure reading will be lower than that of an adult.

Question 12

The nurse is assessing the vital signs of a 20-year-old male marathon runner and documents the following vital signs: temperature-36$\degree$ C; pulse-48 beats per minute; respirations-14 breaths per minute; blood pressure-104/68 mm Hg. Which statement is true concerning these results?

Accepted Answer

A)  The patient is experiencing tachycardia. 
B)  These are normal vital signs for a healthy, athletic adult. 
C)  The patient's pulse rate is not normal-his physician should be notified. 
D)  On the basis of these readings, the patient should return to the clinic in 1 week. 
A)  The patient is experiencing tachycardia. 
B)  These are normal vital signs for a healthy, athletic adult. 
C)  The patient's pulse rate is not normal-his physician should be notified. 
D)  On the basis of these readings, the patient should return to the clinic in 1 week.

Question 13

The nurse will perform a palpated pressure before auscultating blood pressure. What is the reason for this?

Accepted Answer

A)  More clearly hear the Korotkoff sounds. 
B)  Detect the presence of an auscultatory gap. 
C)  Avoid missing a falsely elevated blood pressure. 
D)  More readily identify phase IV of the Korotkoff sounds. 
A)  More clearly hear the Korotkoff sounds. 
B)  Detect the presence of an auscultatory gap. 
C)  Avoid missing a falsely elevated blood pressure. 
D)  More readily identify phase IV of the Korotkoff sounds.

Question 14

The nurse is assessing the vital signs of a 3-year-old patient who appears to have an irregular respiratory pattern. How should the nurse assess this child's respirations?

Accepted Answer

A)  Respirations should be counted for 1 full minute if the nurse suspects an abnormality. 
B)  Child's pulse and respirations should be simultaneously checked for 30 seconds and then multiplied by 2. 
C)  Child's respirations should be checked for a minimum of 5 minutes to identify any variations in his or her respiratory pattern. 
D)  Patient's respirations should be counted for 15 seconds and then multiplied by 4 to obtain the number of respirations per minute. 
A)  Respirations should be counted for 1 full minute if the nurse suspects an abnormality. 
B)  Child's pulse and respirations should be simultaneously checked for 30 seconds and then multiplied by 2. 
C)  Child's respirations should be checked for a minimum of 5 minutes to identify any variations in his or her respiratory pattern. 
D)  Patient's respirations should be counted for 15 seconds and then multiplied by 4 to obtain the number of respirations per minute.

Question 15

When assessing an older adult, the nurse should recognize that which vital sign changes occur with aging?

Accepted Answer

A)  Increase in pulse rate 
B)  Widened pulse pressure 
C)  Increase in body temperature 
D)  Decrease in diastolic blood pressure 
A)  Increase in pulse rate 
B)  Widened pulse pressure 
C)  Increase in body temperature 
D)  Decrease in diastolic blood pressure

Question 16

The nurse has collected the following information on a patient: palpated blood pressure-180 mm Hg; auscultated blood pressure-170/100 mm Hg; apical pulse-60 beats per minute; radial pulse-70 beats per minute. What is the patient's pulse pressure?

Accepted Answer

A)  10 
B)  70 
C)  80 
D)  100 
A)  10 
B)  70 
C)  80 
D)  100

Question 17

The nurse is taking an initial blood pressure reading on a 72-year-old patient with documented hypertension. How should the nurse proceed?

Accepted Answer

A)  Cuff should be placed on the patient's arm and inflated 30 mm Hg above the patient's pulse rate. 
B)  Cuff should be inflated to 200 mm Hg in an attempt to obtain the most accurate systolic reading. 
C)  Cuff should be inflated 30 mm Hg above the point at which the palpated pulse disappears. 
D)  After confirming the patient's previous blood pressure readings, the cuff should be inflated 30 mm Hg above the highest systolic reading recorded. 
A)  Cuff should be placed on the patient's arm and inflated 30 mm Hg above the patient's pulse rate. 
B)  Cuff should be inflated to 200 mm Hg in an attempt to obtain the most accurate systolic reading. 
C)  Cuff should be inflated 30 mm Hg above the point at which the palpated pulse disappears. 
D)  After confirming the patient's previous blood pressure readings, the cuff should be inflated 30 mm Hg above the highest systolic reading recorded.

Exam 10: Vital Signs

A patient's blood pressure is 118/82 mm Hg. He asks the nurse, "What do the numbers mean?" Which is the best reply by the nurse?

What type of blood pressure measurement error is most likely to occur if the nurse does not check for the presence of an auscultatory gap?

The nurse is counting an infant's respirations. Which technique is correct?

The nurse is examining a patient who is complaining of "feeling cold." Which is a mechanism of heat loss in the body?

A 4-month-old child is at the clinic for a well-baby checkup and immunizations. Which of these actions is most appropriate when the nurse is assessing an infant's vital signs?

The nurse is preparing to measure the vital signs of a 6-month-old infant. Which action by the nurse is correct?

The nurse is conducting a health fair for older adults. Which statement is true regarding vital sign measurements in aging adults?

A 70-year-old man has a blood pressure of 150/90 mm Hg in a lying position, 130/80 mm Hg in a sitting position, and 100/60 mm Hg in a standing position. How should the nurse evaluate these findings?

A student is late for his appointment and has rushed across campus to the health clinic. How should the nurse proceed?

When assessing the pulse of a 6-year-old boy, the nurse notices that his heart rate varies with his respiratory cycle, speeding up at the peak of inspiration and slowing to normal with expiration. What action should the nurse take next?

A nurse is helping at a health fair at a local mall. What should the nurse keep in mind when taking blood pressures on a variety of people?

The nurse is assessing the vital signs of a 20-year-old male marathon runner and documents the following vital signs: temperature-36 °\degree° C; pulse-48 beats per minute; respirations-14 breaths per minute; blood pressure-104/68 mm Hg. Which statement is true concerning these results?

The nurse will perform a palpated pressure before auscultating blood pressure. What is the reason for this?

The nurse is assessing the vital signs of a 3-year-old patient who appears to have an irregular respiratory pattern. How should the nurse assess this child's respirations?

When assessing an older adult, the nurse should recognize that which vital sign changes occur with aging?

The nurse has collected the following information on a patient: palpated blood pressure-180 mm Hg; auscultated blood pressure-170/100 mm Hg; apical pulse-60 beats per minute; radial pulse-70 beats per minute. What is the patient's pulse pressure?

The nurse is taking an initial blood pressure reading on a 72-year-old patient with documented hypertension. How should the nurse proceed?

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The nurse is assessing the vital signs of a 20-year-old male marathon runner and documents the following vital signs: temperature-36 $\degree$ C; pulse-48 beats per minute; respirations-14 breaths per minute; blood pressure-104/68 mm Hg. Which statement is true concerning these results?