Chapter 10 Vital Signs Practice Questions Flashcards
A patients weekly blood pressure readings for 2 months have ranged between 124/84 mm Hg and 136/88 mm Hg, with an average reading of 126/86 mm Hg. The nurse knows that this blood pressure falls within which blood pressure category?
a. Normal blood pressure
b. Prehypertension
c. Stage 1 hypertension
d. Stage 2 hypertension
b. Prehypertension
When assessing an older adult, which vital sign changes occur with aging?
a. Increase in pulse rate
b. Widened pulse pressure
c. Increase in body temperature
d. Decrease in diastolic blood pressure
b. Widened pulse pressure
Which technique is correct when the nurse is assessing the radial pulse of a patient?
The pulse is counted for:
a. 1 minute, if the rhythm is irregular.
b. 15 seconds and then multiplied by 4, if the rhythm is regular.
c. 2 full minutes to detect any variation in amplitude.
d. 10 seconds and then multiplied by 6, if the patient has no history of cardiac abnormalities.
a. 1 minute, if the rhythm is irregular.
When assessing a patients pulse, the nurse should also notice which of these characteristics?
a. Force
b. Pallor
c. Capillary refill time
d. Timing in the cardiac cycle
a. Force
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. The nurses next action would be to:
a. Immediately notify the physician.
b. Consider this finding normal in children and young adults.
c. Check the childs blood pressure, and note any variation with respiration.
d. Document that this child has bradycardia, and continue with the assessment.
b. Consider this finding normal in children and young adults.
When assessing the force, or strength, of a pulse, the nurse recalls that the pulse:
a. Is usually recorded on a 0- to 2-point scale.
b. Demonstrates elasticity of the vessel wall.
c. Is a reflection of the hearts stroke volume.
d. Reflects the blood volume in the arteries during diastole.
c. Is a reflection of the hearts stroke volume.
The nurse is assessing the vital signs of a 20-year-old male marathon runner and documents the following vital signs: temperature36 C; pulse48 beats per minute; respirations 14 breaths per minute; blood pressure 104/68 mm Hg. Which statement is true concerning these results?
a. The patient is experiencing tachycardia.
b. These are normal vital signs for a healthy, athletic adult.
c. The patients pulse rate is not normalhis physician should be notified.
d. On the basis of these readings, the patient should return to the clinic in 1 week.
b. These are normal vital signs for a healthy, athletic adult.
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 childs respirations?
a. Respirations should be counted for 1 full minute, noticing rate and rhythm.
b. Childs pulse and respirations should be simultaneously checked for 30 seconds.
c. Childs respirations should be checked for a minimum of 5 minutes to identify any variations in his or her respiratory pattern.
d. Patients 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, noticing rate and rhythm.
A patients blood pressure is 118/82 mm Hg. He asks the nurse, What do the numbers mean? The nurses best reply is:
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.
c. The top number is the systolic blood pressure and reflects the pressure of the blood against the arteries when the heart contracts.
While measuring a patients blood pressure, the nurse recalls that certain factors, such as __________, help determine blood pressure.
a. Pulse rate
b. Pulse pressure
c. Vascular output
d. Peripheral vascular resistance
d. Peripheral vascular resistance
A nurse is helping at a health fair at a local mall. When taking blood pressures on a variety of people, the nurse keeps in mind that:
a. After menopause, blood pressure readings in women are usually lower than those taken in men.
b. The blood pressure of a Black adult is usually higher than that of a 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 teenagers blood pressure reading will be lower than that of an adult.
b. The blood pressure of a Black adult is usually higher than that of a White adult of the same age.
The nurse notices a colleague is preparing to check the blood pressure of a patient who is obese by using a standard-sized blood pressure cuff. The nurse should expect the reading to:
a. Yield a falsely low blood pressure.
b. Yield a falsely high blood pressure.
c. Be the same, regardless of cuff size.
d. Vary as a result of the technique of the person performing the assessment.
b. Yield a falsely high blood pressure.
A student is late for his appointment and has rushed across campus to the health clinic. The nurse should:
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.
The nurse will perform a palpated pressure before auscultating blood pressure. The reason for this is to:
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.
b. Detect the presence of an auscultatory gap.
The nurse is taking an initial blood pressure reading on a 72-year-old patient with documented
hypertension. How should the nurse proceed?
a. Cuff should be placed on the patients arm and inflated 30 mm Hg above the patients 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 patients previous blood pressure readings, the cuff should be inflated 30 mm Hg above the highest systolic reading recorded.
c. Cuff should be inflated 30 mm Hg above the point at which the palpated pulse disappears.
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 patients pulse pressure?
a. 10
b. 70
c. 80
d. 100
b. 70
When auscultating the blood pressure of a 25-year-old patient, the nurse notices the phase I Korotkoff sounds begin at 200 mm Hg. At 100 mm Hg, the Korotkoff sounds muffle. At 92 mm Hg, the Korotkoff sounds disappear. How should the nurse record this patients blood pressure?
a. 200/92
b. 200/100
c. 100/200/92
d. 200/100/92
a. 200/92
A patient is seen in the clinic for complaints of fainting episodes that started last week. How should the nurse proceed with the examination?
a. Blood pressure readings are taken in both the arms and the thighs.
b. The patient is assisted to a lying position, and his blood pressure is taken.
c. His blood pressure is recorded in the lying, sitting, and standing positions.
d. His blood pressure is recorded in the lying and sitting positions; these numbers are then averaged to obtain a mean blood pressure.
c. His blood pressure is recorded in the lying, sitting, and standing positions.
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. These readings are a normal response and attributable to changes in the patients 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 patients age.
b. The change in blood pressure readings is called orthostatic hypotension.
The nurse is helping another nurse to take a blood pressure reading on a patients thigh. Which action is correct regarding thigh pressure?
a. Either the popliteal or femoral vessels should be auscultated to obtain a thigh pressure.
b. The best position to measure thigh pressure is the supine position with the knee slightly bent.
c. If the blood pressure in the arm is high in an adolescent, then it should be compared with the thigh pressure.
d. The thigh pressure is lower than the pressure in the arm, which is attributable to the distance away from the heart and the size of the popliteal vessels.
c. If the blood pressure in the arm is high in an adolescent, then it should be compared with the thigh pressure.
A 4-month-old child is at the clinic for a well-baby check-up and immunizations. Which of these actions is most appropriate when the nurse is assessing an infants vital signs?
a. The infants 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 arrhythmia.
c. The infants blood pressure should be assessed by using a stethoscope with a large diaphragm piece to hear the soft muffled Korotkoff sounds.
d. The infants chest should be observed and the respiratory rate counted for 1 minute; the respiratory pattern may vary significantly.
b. The nurse should auscultate an apical rate for 1 minute and then assess for any normal
irregularities, such as sinus arrhythmia.
The nurse is conducting a health fair for older adults. Which statement istrue 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 phase are expected findings.
c. A decreased pulse pressure occurs from changes in the systolic and diastolic blood pressures.
d. Changes in the bodys temperature regulatory mechanism leave the older person more likely to develop a fever.
b. An increased respiratory rate and a shallower inspiratory phase are expected findings.
In a patient with acromegaly, the nurse will expect to discover which assessment findings?
a. Heavy, flattened facial features
b. Growth retardation and a delayed onset of puberty
c. Overgrowth of bone in the face, head, hands, and feet
d. Increased height and weight and delayed sexual development
c. Overgrowth of bone in the face, head, hands, and feet
The nurse is assessing children in a pediatric clinic. Which statement istrue regarding the measurement of blood pressure in children?
a. Blood pressure guidelines for children are based on age.
b. Phase II Korotkoff sounds are the best indicator of systolic blood pressure in children.
c. Using a Doppler device is recommended for accurate blood pressure measurements until
adolescence.
d. The disappearance of phase V Korotkoff sounds can be used for the diastolic reading in children.
d. The disappearance of phase V Korotkoff sounds can be used for the diastolic reading in children.
