Chapter 10: Vital Signs

Question 1

Auscultatory gap

Answer 1

A brief period when Korotkoff sounds disappear during auscultation of blood pressure; may occur with hypertension

Question 2

Bradycardia

Answer 2

Heart rate fewer than 50 or 60 beats per minute in the adult (depending on the agency)

Question 3

Sphygmomanometer

Answer 3

Instrument for measuring arterial blood pressure

Question 4

Stroke volume

Answer 4

Amount of blood pumped out f the heart with each heartbeat

Question 5

Tachycardia

Answer 5

Heart rate greater than 95 beats per minute in the adult

Question 6

Describe the tympanic membrane and temporal artery thermometers, and compare their use with other forms of temperature measurement.

Answer 6

Oral temperature: convenient and accurate; sublingual pocket has many blood vessels; noninvasive; not necessarily a core temperature

Rectal temperature: invasive; good core temp reading; accurate; used on babies

Tympanic membrane thermometer: senses infrared emissions of eardrum; accurate measure of core temperature; noninvasive; quick and efficient; poor sensitivity of picking up low-grade fever

Temporal artery thermometer: senses infrared emissions from temporal artery; noninvasive, more accurate than tympanic; not sensitive to low-grade fevers

Question 7

Describe 3 qualities to consider when assessing the pulse

Answer 7

Rate: 50-95 bpm in healthy adult; frequency of the heart beat
Rhythm: should be regular and even
Force: strength of heart’s stroke volume; recorded using a 3-point scale (2+ is normal)

Question 8

Relate the qualities of normal respirations to the appropriate approach for counting them

Answer 8

Should be relaxed, regular, automatic, and silent.
Do not tell patients you are counting respirations.
Count for 30 seconds starting at 0 (if abnormal do a full minute).
Age changes normal number. Adult: 10-20 breaths/min

Question 9

Define and describe the relationships among the terms blood pressure, systolic pressure, diastolic pressure, pulse pressure, and mean arterial pressure

Answer 9

Blood pressure (BP): force of the blood pushing against the side of its container (vessel wall) = systolic/diastolic

Systolic pressure: maximum pressure felt on the artery during left ventricle contraction (systole)

Diastolic pressure: the elastic recoil, or resting, pressure that the blood exerts constantly between contraction

Pulse pressure: difference between the systolic and diastolic pressure; reflects the stroke volume

Question 10

List factors that affect blood pressure.

Answer 10

Age: increases with age
Sex: after puberty, females < males; after menopause females > males
Race: African americans > non-hispanic white person
Diurnal rhythm: BP increases until late afternoon and then decreases until early morning
Weight: increased in obese people
Exercise: can increase during exercise
Emotions: sympathetic response (stress, fear, anxiety) increases BP

Question 11

Relate the use of the wrong size blood pressure cuff to the possible findings that might be obtained.

Answer 11

Too narrow causes falsely high blood pressures

Question 12

Explain the significance of phase I, phase IV, and phase V Korotkoff sounds during blood pressure measurement.

Answer 12

Phase I: soft, clear tapping increasing in intensity; systolic pressure; turbulent flow due to high velocity and small opening
Phase IV: Abrupt muffling; blowing quality; change in quality, not intensity
Phase V: silence; decreased velocity of blood flow; diastolic pressure

Question 13

Given an apparently healthy 20-year-old adult, state the expected range for oral temperature, pulse, respirations, and blood pressure.

Answer 13

Oral temp: 96.4-99.1 F (35.8-37.3 C)
Pulse: 50-95 bpm
Respirations: 10-20 breaths/min
BP: 100-120/60-80

Question 14

During an initial home visit, the patient’s temperature is noted to be 97.4F. How would you interpret this?

a. It cannot be evaluated without knowledge of the person’s age
b. It is below normal. The person should be assessed for possible hypothermia
c. It should be retaken by the rectal route, because this best reflects core body temperature
d. It should be reevaluated at the next visit before a decision is made.

Answer 14

a. It cannot be evaluated without knowledge of the person’s age

Question 15

Select the best description of an accurate assessment of a patient’s pulse.

a. Count for 15 seconds if the pulse is regular
b. Begin counting with zero; count for 30 seconds
c. Count for 30 seconds and multiply by 2 for all cases
d. Count for 1 full minute; begin counting with zero

Answer 15

b. Begin counting with zero; count for 30 seconds

Question 16

After assessing the patient’s pulse, the practitioner determines it to be “normal.” This would be recorded as:

a. 3+
b. 2+
c. 1+
d. 0

Answer 16

b. 2+

Question 17

Select the best description of an accurate assessment of a patient’s respirations.

a. Count for a full minute before taking the pulse
b. Count for 15 seconds and multiply by 4
c. Count after informing the patient where you are in the assessment process
d. Count for 30 seconds after pulse assessment

Answer 17

d. Count for 30 seconds after pulse assessment

Question 18

Pulse pressure is described as:

a. The difference between the systolic and diastolic pressure
b. A reflection of the viscosity of the blood
c. Another way to express the systolic pressure
d. A measure of vasoconstriction

Answer 18

a. The difference between the systolic and diastolic pressure

Question 19

The examiner suspects a patient has coarctation of the aorta. Which assessment finding supports this suspicion?

a. The thigh pressure is higher than in the arm
b. The thigh pressure is equal to that int he arm
c. The thigh pressure is unrelated to the arm pressure. There is no constant relationship; findings are highly individual
d. The thigh pressure is lower than in the arm

Answer 19

d. The thigh pressure is lower than in the arm

Question 20

Mean arterial pressure is:

a. The arithmetic average of systolic and diastolic pressures
b. The driving force of blood during systole
c. Diastolic pressure plus one third of the pulse pressure
d. Corresponding to phase III Korotkoff

Answer 20

c. Diastolic pressure plus one third of the pulse pressure

Question 21

Why is it so important to match the appropriate size of blood pressure cuff to the person’s arm and shape and not to the person’s age?

a. Using a cuff that is too narrow will give a false reading that is too high
b. Using a cuff that is too wide will give a false reading that is too low
c. Using a cuff that is too narrow will give a false reading that is too low
d. Using a cuff that is too wide will give a false reading that is too high

Answer 21

a. Using a cuff that is too narrow will give a false reading that is too high

Question 22

A patient is being seen in the clinic for complaints of “fainting episodes that started last week.” How should you proceed with the examination?

a. Take the blood pressure in both arms and thighs
b. Ask the person to walk a few paces and then take the blood pressure
c. Record the blood pressure in the lying, sitting, and standing positions
d. Record the blood pressure in the lying and sitting positions and average these numbers to obtain a mean blood pressure

Answer 22

c. Record the blood pressure in the lying, sitting, and standing positions

Question 23

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

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 rate are possible findings
c. A decreased pulse pressure occurs from changes in systolic and diastolic blood pressures
d. Changes in the body’s temperature regulatory mechanism leave the older adult more likely to develop a fever

Answer 23

b. An increased respiratory rate and a shallower inspiratory rate are possible findings

Question 24

Analyze the vital sign values. Note any additional information you need to fully analyze the values. 
55-year-old women
T: 37C
R: 18 breaths/minute
P: 160 bpm
BP: 90/60 mmHg

Answer 24

Increased heart rate

Low blood pressure

Question 25

Analyze the vital sign values. Note any additional information you need to fully analyze the values. 
2-year-old boy
T: 37C
R: 18 breaths/minute
P: 130 bpm

Answer 25

Elevated heart rate

Would want to see BP, general appearance, rhythm of heart rate

Question 26

Analyze the vital sign values. Note any additional information you need to fully analyze the values. 
89-year-old women
T: 36C
R: 12 breaths/minute
P: 55 bpm
BP: 140/98 mmHg

Answer 26

Elevated blood pressure

Question 27

Analyze the vital sign values. Note any additional information you need to fully analyze the values. 
25-year-old man
T: 39C
R: 26 breaths/minute
P: 113 bpm
BP: 100/60 mmHg

Answer 27

Temperature
Increased respirations
Increased pulse
Low/normal blood pressure

Question 28

Factors that determine level of blood pressure

Answer 28

Cardiac output 
Vascular resistance 
Volume 
Viscosity
Elasticity of arteries