Ch 25

Question 1

A diagnosis of hypertension is made when the systolic pressure is _______ mm Hg or higher or the diastolic pressure is 90 mm Hg or higher.

Answer 1

130

Question 2

Shivering, a response that increases the production of heat, is initiated by the _____________ and results in muscle tremors, resulting in the production of heat.

Answer 2

hypothalamus

Question 3

The pulse is regulated by the _____________ nervous system through the sinoatrial (SA) node, the pacemaker of the heart.

Answer 3

autonomic

Question 4

T or F: The core body temperature is maintained within a fairly constant range by the thermoregulatory center in the hypothalamus.

Answer 4

Ture

Question 5

The mechanics of heat transfer, known as _____________, refers to the transfer of heat to another object during direct contact.

Answer 5

conduction

Question 6

T or F: The nurse should know that a systolic blood pressure reading greater than 100 mm Hg is abnormal in a toddler.

Answer 6

Ture

Question 7

A difference between the apical and radial pulse rates, called the pulse _______, indicates that all of the heartbeats are not reaching the peripheral arteries or are too weak to be palpated.

Answer 7

deficit

Question 8

The nurse is assessing the pulse of a young adult who is training for a triathlon competition. The pulse rate is 48 beats/min. What education should the nurse provide to the client?

Answer 8

The heart rate is within normal limits due to the exercise regimen the client is following.

Question 9

The nurse is assessing the apical pulse of a client using auscultation. What action would the nurse perform after placing the diaphragm over the apex of the heart?

Answer 9

Listen for heart sounds.

Question 10

When assessing a client’s radial pulse, the nurse notes an irregular rhythm with a rate of 62 beats per minute. What intervention should the nurse implement next?

Answer 10

Auscultate the apical pulse for 60 seconds

Question 11

During a routine vital sign assessment, the nurse notes that the client’s blood pressure is 212/110 mm Hg. Which is the nurse’s next action?

Answer 11

Have the client rest for 5 minutes, then retake the blood pressure.

Question 12

A pulse deficit is the difference between:

Answer 12

the apical and the radial pulse rates.

Question 13

When assessing a client’s radial pulse, the nurse notes an irregular rhythm with a rate of 62 beats per minute. What intervention should the nurse implement next?

Answer 13

Auscultate the apical pulse for 60 seconds

Question 14

The student nurse is having difficulty feeling the pedal pulse of the client with a fractured leg. What should the nurse do next?

Answer 14

Use the Doppler ultrasound device.

Question 15

Which outcome best reflects achievement of the goal, “The client will demonstrate correct steps in taking his own pulse rate”?

Answer 15

palpation of the radial pulse on the thumb side of the inner aspect of the wrist.

Question 16

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?

Answer 16

There is an auscultatory gap.

Question 17

The nurse understands that accurate blood pressure taking is dependent on several factors. Which example will most likely render an accurate blood pressure reading?

Answer 17

placing the client’s arm at heart level

Question 18

When administering beta blocker medications, the health care provider adds an order to hold medication when the client is bradycardic. Which statement explains this order?

Answer 18

The client’s pulse rate is below 60 beats per minute.

Question 19

Which client’s blood pressure best describes the condition called hypotension?

Answer 19

The systolic reading is below 100 and diastolic reading is below 60.

Question 20

The body loses heat continually through several different processes. Which process is an example of how heat is lost through evaporation?

Answer 20

diaphoresis

Question 21

A nurse can most accurately assess a client’s heart rate and rhythm by which of the following methods?

Answer 21

listen with the stethoscope at the fifth intercostal space left mid-clavicular line

Question 22

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?

Answer 22

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.

Question 23

After taking vital signs of an older adult, the nurse writes down findings as T = 98.9/37.2 oral, P = 104, R = 18, BP = 120/82. Based on the collected data, which step would the nurse take next?

Answer 23

Take pulse again to assess for tachycardia

Question 24

A nurse is assessing an apical pulse on a cardiac client. The client is taking digoxin, which is a cardiac medication. The nurse can anticipate that the digoxin will:

Answer 24

decrease the apical pulse.

Question 25

A nurse will assess the oral temperature of a postoperative client. Prior to performing this assessment, which should the nurse identify?

Answer 25

The client’s most recent temperature

Question 26

The nurse is preparing to administer a medication that the client takes to treat a cardiac arrythmia. Which site should the nurse use to assess pulse in this client?

Answer 26

apical

Question 27

While recording the pulse of an infant at 160 beats/min, the parent asks if it is normal for the infant’s pulse rate to be so high. Which statement by the nurse best answers the parent’s question?

Answer 27

“A heart rate of 160 beats/min is normal for a healthy infant.”

Question 28

The nurse is obtaining vital signs for a client and assesses a heart rate of 124 beats per minute. What additional assessment information would be important to obtain that would explain the tachycardia? Select all that apply.

Answer 28

The client has reports of pain of 8 on a scale of 0 to 10

The client just finished ambulating with physical therapy

The client has a temperature of 101.8°F (38.8°C)

Question 29

A nursing student is manually taking the client’s blood pressure. Which step will demonstrate the correct way of inflating the blood pressure cuff?

Answer 29

Inflate the cuff to 30 mm Hg above reading where brachial pulse disappeared.

Question 30

A nurse is assessing the respirations of a 60-year-old female client and finds that the client’s breaths are so shallow that the respirations cannot be counted. What would be the appropriate initial nursing intervention in this situation?

Answer 30

Auscultate the lung sounds and count respirations.

Question 31

A nurse needs to count a client’s heart rate. For which reason would the nurse assess the client’s apical pulse?

Answer 31

The radial pulse is difficult to obtain.