Chapter 10: Vital Signs
Jarvis: Physical Examination and Health Assessment, 8th Edition
MULTIPLE CHOICE
1. The nurse should measure rectal temperatures in which of these patients?
a.
Older adult
b.
Comatose adult
c.
School-age child
d.
Patient receiving oxygen by nasal cannula
2. The nurse is teaching a student nurse about the different types of thermometers. When
teaching the student about the advantages of the tympanic membrane thermometer (TMT),
which statement should the nurse include?
a.
“Measuring temperature using the TMT is inexpensive.”
b.
“The rapid measurement of the TMT is useful for uncooperative younger
children.”
c.
“Using the TMT is the most accurate method for measuring body temperature in
newborn infants.”
d.
“Studies strongly support the use of the TMT in children under the age 6 years.”
3. When assessing an older adult, the nurse should recognize that 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
4. The nurse is examining a patient who is complaining of “feeling cold.” Which is a mechanism
of heat loss in the body?
a.
Exercise
b.
Radiation
c.
Metabolism
d.
Food digestion
5. When measuring a patient’s body temperature, the nurse should keep in mind that what can
influence the temperature?
a.
Constipation
b.
Diurnal cycle
c.
Nocturnal cycle
d.
Patient’s emotional state
6. When evaluating the temperature of older adults, the nurse should remember which aspect
about an older adult’s body temperature?
a.
The body temperature of the older adult is lower than that of a younger adult.
b.
An older adult’s body temperature is approximately the same as that of a young
child.
c.
Body temperature depends on the type of thermometer used.
d.
In the older adult, the body temperature varies widely because of less effective heat
control mechanisms.
7. Which of these actions illustrates the correct technique the nurse should use when assessing
oral temperature with a glass thermometer?
a.
Wait 30 minutes if the patient has ingested hot or iced liquids.
b.
Leave the thermometer in place for 3 to 4 minutes if the patient is afebrile.
c.
Shake the glass thermometer down to 37.5 C before taking the patient’s
temperature.
d.
Place the thermometer in front of the tongue and ask the patient to close his or her
lips.
8. What technique should the nurse use to accurately assess a rectal temperature in an adult?
a.
Use a lubricated blunt tip thermometer.
b.
Insert the thermometer 2 to 3 inches into the rectum.
c.
Leave the thermometer in place up to 8 minutes if the patient is febrile.
d.
Wait 2 to 3 minutes if the patient has recently smoked a cigarette.
9. Which technique is correct when the nurse is assessing the radial pulse of a patient?
a.
Palpate for 1 minute, if the rhythm is irregular.
b.
Palpate for 15 seconds and multiply by 4, if the rhythm is regular.
c.
Palpate for 2 full minutes to detect any variation in amplitude.
d.
Palpate for 10 seconds and multiply by 6, if the rhythm is regular and the patient
has no history of cardiac abnormalities.
10. When assessing a patient’s pulse, the nurse should also notice which of these characteristics?
a.
Force
b.
Pallor
c.
Capillary refill time
d.
Timing in the cardiac cycle
11. 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.
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.
12. When assessing the force, or strength, of a pulse, what should the nurse recall about the pulse?
a.
Is a reflection of the heart’s stroke volume
b.
Typically recorded on a 0- to 2-point scale
c.
Demonstrates elasticity of the blood vessel wall
d.
Reflects the blood volume in the arteries during diastole
13. The nurse is assessing the vital signs of a 20-year-old male marathon runner and documents
the following vital signs: temperature–36 C; pulse–48 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 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.
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?
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.
15. 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?
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.”
16. While measuring a patient’s blood pressure, the nurse should recall that which is a factor that
influences a patient’s blood pressure?
a.
Pulse rate
b.
Pulse pressure
c.
Vascular output
d.
Peripheral vascular resistance
17. 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?
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.
18. The nurse notices that a colleague is preparing to check the blood pressure of a patient who is
obese by using a standard-sized blood pressure cuff. How would this likely affect the blood
pressure reading?
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
19. A student is late for his appointment and has rushed across campus to the health clinic. How
should the nurse proceed?
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.
20. The nurse will perform a palpated pressure before auscultating blood pressure. What is the
reason for this?
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.
21. 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 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.
22. 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?
a.
10
b.
70
c.
80
d.
100
23. When auscultating the blood pressure of a 25-year-old patient, the nurse notices that 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 patient’s blood
pressure?
a.
200/92
b.
200/100
c.
100/200/92
d.
200/100/92
24. 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.
25. 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 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.
26. The nurse is helping another nurse take a blood pressure reading on a patient’s 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.
27. The nurse is preparing to measure the vital signs of a 6-month-old infant. Which action by the
nurse is correct?
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.
28. 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?
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.
29. 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 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.
30. The nurse is assessing children in a pediatric clinic. Which statement is true 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.
31. 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?
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.
32. When considering the concepts r/t blood pressure, the nurse knows that the concept of mean
arterial pressure (MAP) is best described by which statement?
a.
MAP is the pressure of the arterial pulse.
b.
MAP reflects the stroke volume of the heart.
c.
MAP is the pressure forcing blood into the tissues, averaged over the cardiac cycle.
d.
MAP is an average of the systolic and diastolic blood pressures and reflects tissue
perfusion.
33. A 75-year-old man with a history of hypertension was recently changed to a new
antihypertensive drug. He reports feeling dizzy at times. How should the nurse evaluate his
blood pressure?
a.
Blood pressure and pulse should be recorded in the supine, sitting, and standing
positions.
b.
The patient should be directed to walk around the room and his blood pressure
assessed after this activity.
c.
Blood pressure and pulse are assessed at the beginning and at the end of the
examination.
d.
Blood pressure is taken on the right arm and then 5 minutes later on the left arm.
34. The nurse is counting an infant’s respirations. Which technique is correct?
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
35. When checking for proper blood pressure cuff size, which guideline is correct?
a.
The standard cuff size is appropriate for all sizes.
b.
The length of the rubber bladder should equal 80% of the arm circumference.
c.
The width of the rubber bladder should equal 80% of the arm circumference.
d.
The width of the rubber bladder should equal 40% of the arm circumference.
MULTIPLE RESPONSE
1. While measuring a patient’s blood pressure, the nurse uses the proper technique to obtain an
accurate reading. Which of these situations will result in a falsely high blood pressure
reading? (Select all that apply.)
a.
The person supports his or her own arm during the blood pressure reading.
b.
The blood pressure cuff is too narrow for the extremity.
c.
The arm is held above level of the heart.
d.
The cuff is loosely wrapped around the arm.
e.
The person is sitting with his or her legs crossed.
f.
The nurse does not inflate the cuff high enough.
COMPLETION
1. What is the pulse pressure for a patient whose blood pressure is 158/96 mm Hg and whose
pulse rate is 72 beats per minute? __________
