Chapter 20 Vital Signs

Chapter 20 Vital Signs

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question.1)A nurse is assessing the popliteal pulses of a client with peripheral vascular disease. The client islying supine in the bed. The nurse is unable to palpate a pulse at the left popliteal site. What is acorrect action by the nurse at this time?1)A)Document that the right popliteal pulse is palpable and the left popliteal pulse is notpalpable.B)Assist the client to a prone position, flex the left knee slightly, and then reassess the leftpopliteal pulse.C)Ask the client to sit on the side of the bed for 1 minute, and then reassess both poplitealpulses.D)Have the client lie on the right side and reassess the left popliteal pulse.Answer:BExplanation:A)A prone position and slight flexion of the left knee relaxes the muscles around thepopliteal artery, and may help in the pulse assessment. It is appropriate to furtherassess after repositioning, rather than proceeding to document the absent pulse.Having the client lie on the right side will not have an effect on the pulse intensity.Having the client sit on the side of the bed will decrease access to the pulse site.AssessmentPhysiological Integrity-Reduction of Risk PotentialApplicationB)A prone position and slight flexion of the left knee relaxes the muscles around thepopliteal artery, and may help in the pulse assessment. It is appropriate to furtherassess after repositioning, rather than proceeding to document the absent pulse.Having the client lie on the right side will not have an effect on the pulse intensity.Having the client sit on the side of the bed will decrease access to the pulse site.AssessmentPhysiological Integrity-Reduction of Risk PotentialApplicationC)A prone position and slight flexion of the left knee relaxes the muscles around thepopliteal artery, and may help in the pulse assessment. It is appropriate to furtherassess after repositioning, rather than proceeding to document the absent pulse.Having the client lie on the right side will not have an effect on the pulse intensity.Having the client sit on the side of the bed will decrease access to the pulse site.AssessmentPhysiological Integrity-Reduction of Risk PotentialApplicationD)A prone position and slight flexion of the left knee relaxes the muscles around thepopliteal artery, and may help in the pulse assessment. It is appropriate to furtherassess after repositioning, rather than proceeding to document the absent pulse.Having the client lie on the right side will not have an effect on the pulse intensity.Having the client sit on the side of the bed will decrease access to the pulse site.AssessmentPhysiological Integrity-Reduction of Risk PotentialApplication1
2)A nurse has obtained a blood pressure reading of 144/90. The client asks what the number 90means. The nurse should tell the client that this number:2)A)Represents the pressure present at all times within the arteries.B)Reflects the pressure of the left ventricle of the heart when it is contracting.C)Is the pulse pressure.D)Is abnormally high.Answer:AExplanation:A)The number 90 in this blood pressure reading is the diastolic pressure, which is thepressure at which the blood runs freely through the arteries. Unless there isvasoconstriction, this is the amount of pressure it takes to pump the blood throughthe peripheral arteries. A diastolic of 90 is high (not abnormally) and may indicatehypertension. The pressure of the left ventricle of the heart when it is contractingdescribes the systolic pressure. Pulse pressure is the difference between systolicand diastolic pressure.ImplementationHealth Promotion and MaintenanceApplicationB)The number 90 in this blood pressure reading is the diastolic pressure, which is thepressure at which the blood runs freely through the arteries. Unless there isvasoconstriction, this is the amount of pressure it takes to pump the blood throughthe peripheral arteries. A diastolic of 90 is high (not abnormally) and may indicatehypertension. The pressure of the left ventricle of the heart when it is contractingdescribes the systolic pressure. Pulse pressure is the difference between systolicand diastolic pressure.ImplementationHealth Promotion and MaintenanceApplicationC)The number 90 in this blood pressure reading is the diastolic pressure, which is thepressure at which the blood runs freely through the arteries. Unless there isvasoconstriction, this is the amount of pressure it takes to pump the blood throughthe peripheral arteries. A diastolic of 90 is high (not abnormally) and may indicatehypertension. The pressure of the left ventricle of the heart when it is contractingdescribes the systolic pressure. Pulse pressure is the difference between systolicand diastolic pressure.ImplementationHealth Promotion and MaintenanceApplicationD)The number 90 in this blood pressure reading is the diastolic pressure, which is thepressure at which the blood runs freely through the arteries. Unless there isvasoconstriction, this is the amount of pressure it takes to pump the blood throughthe peripheral arteries. A diastolic of 90 is high (not abnormally) and may indicatehypertension. The pressure of the left ventricle of the heart when it is contractingdescribes the systolic pressure. Pulse pressure is the difference between systolicand diastolic pressure.ImplementationHealth Promotion and MaintenanceApplication2
3)A client is started on digoxin (Lanoxin) once a day. Prior to discharge, the client is taught to obtainhis pulse reading for 1 minute and to call the physician for further instructions if the pulse rate isbelow 60 beats per minute. The most appropriate site for the client to assess his pulse is:3)A)The apical site by placing his hand over his heart.B)The radial artery.C)The apical site using a stethoscope.D)The carotid artery.Answer:BExplanation:A)The radial artery is the easiest site for a client to access, palpate, and count thepulse rate. The wrist is readily accessible, does not require the client to remove anyclothing, and is an area of the body where an artery is near enough to the surfacefor easy palpation. The client does not need to purchase or be taught to use astethoscope. Using the hand to palpate the apical pulse will be less accurate. Thecarotid pulse is used primarily to assess circulation to the brain and possiblecardiac arrest.ImplementationPhysiological Integrity-Reduction of Risk PotentialApplicationB)The radial artery is the easiest site for a client to access, palpate, and count thepulse rate. The wrist is readily accessible, does not require the client to remove anyclothing, and is an area of the body where an artery is near enough to the surfacefor easy palpation. The client does not need to purchase or be taught to use astethoscope. Using the hand to palpate the apical pulse will be less accurate. Thecarotid pulse is used primarily to assess circulation to the brain and possiblecardiac arrest.ImplementationPhysiological Integrity-Reduction of Risk PotentialApplicationC)The radial artery is the easiest site for a client to access, palpate, and count thepulse rate. The wrist is readily accessible, does not require the client to remove anyclothing, and is an area of the body where an artery is near enough to the surfacefor easy palpation. The client does not need to purchase or be taught to use astethoscope. Using the hand to palpate the apical pulse will be less accurate. Thecarotid pulse is used primarily to assess circulation to the brain and possiblecardiac arrest.ImplementationPhysiological Integrity-Reduction of Risk PotentialApplicationD)The radial artery is the easiest site for a client to access, palpate, and count thepulse rate. The wrist is readily accessible, does not require the client to remove anyclothing, and is an area of the body where an artery is near enough to the surfacefor easy palpation. The client does not need to purchase or be taught to use astethoscope. Using the hand to palpate the apical pulse will be less accurate. Thecarotid pulse is used primarily to assess circulation to the brain and possiblecardiac arrest.ImplementationPhysiological Integrity-Reduction of Risk PotentialApplication