TB-Chapter 10 Vital Signs PDF

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These are test bank questions that I paid for. All of the exams use these questions from the test banks....

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PHYSICAL EXAMINATION AND HEALTH ASSESSMENT 8TH EDITION JARVIS TEST BANK

TestBank-PhysicalExaminationandHealthAssessment8e(byJarvis)

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Chapter10:VitalSigns MULTIPLECHOICE 1.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

ANS:B AccordingtotheSeventhReportoftheJointNationalCommittee(JNC7)guidelines,prehypertensionblood pressurereadingsaresystolicreadingsof120to139mmHgordiastolicreadingsof50to89mmHg. DIF:CognitiveLevel:Understanding(Comprehension) MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare 2.Whenassessinganolderadult,whichvitalsignchangesoccurwithaging? NURSINGTB.COM a.

Increaseinpulserate

b.

Widenedpulsepressure

c.

Increaseinbodytemperature

d.

Decreaseindiastolicbloodpressure

ANS:B Withaging,thenursekeepsinmindthatthesystolicbloodpressureincreases,leadingtowidenedpulse pressure.Withmanyolderpeople,boththesystolicanddiastolicpressuresincrease.Thepulserateand temperaturedonotincrease. DIF:CognitiveLevel:Understanding(Comprehension) MSC:ClientNeeds:HealthPromotionandMaintenance 3.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.

NURSINGTB.COM

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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.

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ANS:A Recentresearchsuggeststhatthe30-secondintervalmultipliedby2isthemostaccurateandefficient techniquewhenheartratesarenormalorrapidandwhenrhythmsareregular.Iftherhythmisirregular,then thepulseiscountedfor1fullminute. DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare 4.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

NURSINGTB.COM

ANS:A Thepulseisassessedforrate,rhythm,andforce. DIF:CognitiveLevel:Understanding(Comprehension) MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare 5.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.

ANS:B Sinusarrhythmiaiscommonlyfoundinchildrenandyoungadults.Duringtherespiratorycycle,theheartrate varies,speedingupatthepeakofinspirationandslowingtonormalwithexpiration.

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DIF:CognitiveLevel:Analyzing(Analysis) MSC:ClientNeeds:HealthPromotionandMaintenance 6.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.

ANS:C Theheartpumpsanamountofblood(thestrokevolume)intotheaorta.Theforceflaresthearterialwallsand generatesapressurewave,whichisfeltintheperipheryasthepulse. DIF:CognitiveLevel:Remembering(Knowledge) MSC:ClientNeeds:General 7.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;respirations14breathsperminute;blood pressure104/68mmHg.Whichstatementistrueconcerningtheseresults? NURSINGTB.COM

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.

ANS:B Intheadult,aheartratelessthan50beatsperminuteiscalledbradycardia,whichnormallyoccursinthewelltrainedathletewhoseheartmuscledevelopsalongwiththeskeletalmuscles. DIF:CognitiveLevel:Analyzing(Analysis) MSC:ClientNeeds:HealthPromotionandMaintenance 8.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.

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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.

ANS:A Respirationsarecountedfor1fullminuteifanabnormalityissuspected.Theotherresponsesarenotcorrect actions. DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:HealthPromotionandMaintenance 9.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.

NURSINGTB.COM 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.

ANS:C Thesystolicpressureisthemaximumpressurefeltonthearteryduringleftventricularcontraction,orsystole. Thediastolicpressureistheelasticrecoil,orresting,pressurethatthebloodconstantlyexertsinbetweeneach contraction.Thenurseshouldanswerthepatientsquestionandusetermshecanunderstand. DIF:CognitiveLevel:Analyzing(Analysis) MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare 10.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

ANS:D

NURSINGTB.COM

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Thelevelofbloodpressureisdeterminedbyfivefactors:cardiacoutput,peripheralvascularresistance, volumeofcirculatingblood,viscosity,andelasticityofthevesselwalls. DIF:CognitiveLevel:Remembering(Knowledge) MSC:ClientNeeds:General 11.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.

ANS:B IntheUnitedStates,aBlackadultsbloodpressureisusuallyhigherthanthatofaWhiteadultofthesameage. TheincidenceofhypertensionistwiceashighinBlacksasitisinWhites.Aftermenopause,bloodpressurein womenishigherthaninmen;bloodpressuremeasurementsinpeoplewhoareobeseareusuallyhigherthanin thosewhoarenotoverweight.Normally,agradualriseoccursthroughchildhoodandintotheadultyears. DIF:CognitiveLevel:Applying(Application)NURSINGTB.COM MSC:ClientNeeds:PhysiologicIntegrity 12.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.

ANS:B Usingacuffthatistoonarrowyieldsafalselyhighbloodpressurebecauseittakesextrapressuretocompress theartery. DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare 13.Astudentislateforhisappointmentandhasrushedacrosscampustothehealthclinic.Thenurseshould:

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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.

ANS:A Acomfortable,relaxedpersonyieldsavalidbloodpressure.Manypeopleareanxiousatthebeginningofan examination;thenurseshouldallowatleasta5-minuterestperiodbeforemeasuringbloodpressure. DIF:CognitiveLevel:Analyzing(Analysis) MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare 14.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. NURSINGTB.COM

c.

Avoidmissingafalselyelevatedbloodpressure.

d.

MorereadilyidentifyphaseIVoftheKorotkoffsounds.

ANS:B Inflationofthecuff20to30mmHgbeyondthepointatwhichapalpatedpulsedisappearswillavoidmissing anauscultatorygap,whichisaperiodwhentheKorotkoffsoundsdisappearduringauscultation. DIF:CognitiveLevel:Understanding(Comprehension) MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare 15.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.

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PHYSICAL EXAMINATION AND HEALTH ASSESSMENT 8TH EDITION JARVIS TEST BANK TestBank-PhysicalExaminationandHealthAssessment8e(byJarvis)

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ANS:C Anauscultatorygapoccursinapproximately5%ofthepeople,mostofteninthosewithhypertension.To checkforthepresenceofanauscultatorygap,thecuffshouldbeinflated20to30mmHgbeyondthepointat whichthepalpatedpulsedisappears. DIF:CognitiveLevel:Analyzing(Analysis) MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare 16.Thenursehascollectedthefollowinginformationonapatient:palpatedbloodpressure180mmHg; auscultatedbloodpressure170/100mmHg;apicalpulse60beatsperminute;radialpulse70beatsperminute. Whatisthepatientspulsepressure? a.

10

b.

70

c.

80

d.

100

ANS:B NURSINGTB.COM Pulsepressureisthedifferencebetweensystolicanddiastolicbloodpressure(170100=70)andreflectsthe strokevolume.

DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:PhysiologicIntegrity 17.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

ANS:A Inadults,thelastaudiblesoundbestindicatesthediastolicpressure.Whenavarianceisgreaterthan10to12 mmHgbetweenphasesIVandV,bothphasesshouldberecordedalongwiththesystolicreading(e.g., 142/98/80). DIF:CognitiveLevel:Analyzing(Analysis)

NURSINGTB.COM

PHYSICAL EXAMINATION AND HEALTH ASSESSMENT 8TH EDITION JARVIS TEST BANK TestBank-PhysicalExaminationandHealthAssessment8e(byJarvis)

125

MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare 18.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.

ANS:C Ifthepersonisknowntohavehypertension,istakingantihypertensivemedications,orreportsahistoryof faintingorsyncope,thenthebloodpressurereadingshouldbetakeninthreepositions:lying,sitting,and standing. DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare 19.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? NURSINGTB.COM

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.

ANS:B Orthostatichypotensionisadropinsystolicpressureofmorethan20mmHg,whichoccurswithaquick changetoastandingposition.Agingpeoplehavethegreatestriskofthisproblem. DIF:CognitiveLevel:Analyzing(Analysis) MSC:ClientNeeds:HealthPromotionandMaintenance 20.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.

NURSINGTB.COM

PHYSICAL EXAMINATION AND HEALTH ASSESSMENT 8TH EDITION JARVIS TEST BANK TestBank-PhysicalExaminationandHealthAssessment8e(byJarvis)

126

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.

ANS:C Whenbloodpressuremeasuredatthearmisexcessivelyhigh,particularlyinadolescentsandyoungadults,it iscomparedwiththighpressuretocheckforcoarctationoftheaorta.Thepoplitealarteryisauscultatedforthe reading.Generally,thighpressureishigherthanthatofthearm;however,ifcoarctationofthearteryispresent thenarmpressuresarehigherthanthighpressures. DIF:CognitiveLevel:Understanding(Comprehension) MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare 21.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.

NURSINGTB.COM

ANS:B Thenursepalpatesorauscultatesanapicalratewithinfantsandtoddlers.Thepulseshouldbecountedfor1 fullminutetoaccountfornormalirregularities,suchassinusarrhythmia.Childrenyoungerthan3yearsofage havesuchsmallarmvessels;consequently,hearingKorotkoffsoundswithastethoscopeisdifficult.Thenurse shoulduseeitheranelectronicbloodpressuredevicethatusesoscillometryoraDopplerultrasoundd...