 Show Copyright © 2020, Elsevier Inc. All Rights Reserved. 1 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 ANS: B Rectal temperatures should be taken when the other routes are impractical, such as for comatose or confused people, for those in shock, or for those who cannot close the mouth because of breathing or oxygen tubes, a wired mandible, or other facial dysfunctions. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance 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.” ANS: B The TMT is useful for young children who may not cooperate for oral temperatures and fear rectal temperatures. However, the use of a TMT with newborn infants and young children is conflicting. DIF: Cognitive Level: Applying (Application) MSC: Client Needs: Health Promotion and Maintenance 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 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 with aging. However, both the systolic and diastolic pressures increase in many older adults. DIF: Cognitive Level: Understanding (Comprehension) MSC: Client Needs: Health Promotion and Maintenance 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 ANS: B The body maintains a steady temperature through a thermostat or feedback mechanism, which is regulated in the hypothalamus of the brain. The hypothalamus regulates heat production from metabolism, exercise, food digestion, and external factors with heat loss through radiation, evaporation of sweat, convection, and conduction. DIF: Cognitive Level: Remembering (Knowledge) MSC: Client Needs: General 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 ANS: B Normal temperature is influenced by the diurnal cycle, exercise, and age. The other responses do not influence body temperature. Constipation and patient’s emotional state do not influence body temperature. Nocturnal cycle is not a real term. DIF: Cognitive Level: Remembering (Knowledge) MSC: Client Needs: General What characteristics of the pulse should you always assess?The pulse rhythm, rate, force, and equality are assessed when palpating pulses.
Which technique is correct when the nurse is assessing the radial pulse?Radial pulse
To achieve the correct position, place two fingertips directly alongside the radial styloid, just to the inside (Fig 3, attached). Turn the patient's hand over to allow it to hang from your fingertips.
When assessing the radial pulse of a patient the nurse should count the?Measure the radial pulse for 1 minute, wait 5 minutes, and then measure the apical pulse for 1 minute. Ask another health care provider to count the radial pulse while the nurse counts the apical pulse.
When assessing the pulse which parameters are included quizlet?Three components that the nurse should include when documenting pulse (P) are the rate, rhythm, and depth. D. To calculate the pulse of a patient whose rhythm is irregular, the nurse should count the pulse rate for 30 seconds and multiply by two.
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When assessing a patients pulse the nurse should also notice which of these characteristics?
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