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Jarvis Physical Examination and Health Assessment, 8th Ed Terms in this set (42)Which thermometer can measure the oral temperature of a child within 25 seconds? he electronic thermometer with a blue-tipped probe RationaleThe electronic thermometer with a blue-tipped
probe measures oral temperature within 20 to 30 seconds. The glass thermometer measures oral temperature within 2 to 3 minutes, not within 25 seconds. The tympanic membrane thermometer records temperature by detecting infrared radiation from the tympanic membrane and, therefore, does not help measure oral temperature. The temporal artery thermometer detects infrared emissions from the temporal artery thereby recording the temperature; it does not detect oral temperature. Which respiratory rate is normal for a 9-year-old patient? 22 breaths per minute Which nursing intervention will help the nurse accurately measure respiratory rate in an obese patient? Feel the breaths by placing a hand on the patient's abdomen. Which conditions may cause hyperthermia in a patient? Select all that apply. Infection The blood pressure taken in which location will be the highest in the patient with coarctation of the aorta? Upper arm RationaleNormally the thigh blood pressure is higher than in the arm, but a patient with Which factors acutely affect blood pressure? Select all that apply. Blood viscosity Which symptoms are expected in a patient suffering from an acute myocardial infarction? Select all that apply. Hypotension Which physiologic changes result in hypertension? Select all that apply. Increased blood volume The nurse is measuring a patient's thigh blood pressure (BP). Which is the most important point that the nurse should remember about thigh pressure? It is higher than in the arm. Which findings would the nurse expect in the patient with hemorrhagic shock? Select all that apply. Weak, thready pulse Which vital sign in a healthy 90-year-old patient is likely as a result of the aging process? Temperature 95.8°F Which is an appropriate step to take before assessing a patient's blood pressure? Check that the patient's feet are flat on the floor. At which age would the nurse begin routine monitoring of blood pressure in children at low risk for hypertension? 3 years Which organ is considered the thermostat of the human body? Hypothalamus Which vital sign change is expected in an older adult? More easily palpable pulse Which finding would the nurse consider abnormal when obtaining the heart rate of a 20-year-old patient who runs marathons? 105 beats per minute The nurse counts the pulse of a patient with an irregular heart rate for how many seconds? 60 Which factors directly affect blood pressure? Select all that apply. Age Which describes orthostatic hypotension? A decrease in blood pressure moving from supine to standing positions Which manner of counting would the nurse use to assess the respiratory rate of a patient with shallow breathing? Count for a full 60 seconds straight The nurse determines the pedal pulses of a patient to be full
and 3+ A decrease in which characteristic is responsible for hypotension after an acute myocardial infarction? Cardiac output The pulse of a patient with acute anxiety would have which characteristic? Full and bounding Which route would the nurse use to assess temperature with an electronic thermometer with a red-tipped probe? Rectal Which condition would the nurse suspect in a patient with consistent blood pressure readings averaging 160/90 mm Hg? Hypertension Which phase of the Korotkoff sounds is documented as the systolic blood pressure reading? I RationaleThe first (I) sound heard as the blood pressure cuff begins to deflate is the first The neonate has a respiratory rate of 64 breaths per minute. The nurse uses which term to document this finding? Tachypnea RationaleThe neonate with tachypnea may have a respiratory rate of more than 60 breaths per The patient with a history of hypertension has a standing blood pressure of 90/60 mm Hg. Which intervention would the nurse perform first? Assess the blood pressure again. Which statement by the nursing student indicates effective learning about blood pressure cuff sizes? "A cuff size too narrow for a patient will give a false high blood pressure (BP)." Which statement about taking oral temperatures is correct? "Drinking hot liquids may alter the temperature reading." Which vital sign will the nurse assess first in the patient with a history of cardiac dysrhythmias? Pulse The patient with no history of hypertension has a blood pressure reading of 190/100 mm Hg. Which action by the nurse is appropriate? Determine appropriate cuff size Which type of Korotkoff sound would the nurse correlate with the systolic blood pressure? Tapping sounds Which action by the student nurse measuring blood pressure requires further teaching? Pausing during descent and reinflating the cuff The patient's blood pressure is 120/74 mm Hg and heart rate is 80 beats per minute. Which number would the nurse record as the pulse pressure? 46 Rationale: Pulse pressure is the
difference between systolic and diastolic pressures. This number reflects the stroke volume. For a patient with a blood pressure of 120/74 mm Hg and a heart rate of 80 bpm, the equation to find pulse pressure would be: 120 - 74 = 46. The diastolic blood pressure is 74. The heart rate is 80. The systolic blood pressure is 120. Which action would the nurse perform before initially inflating the cuff during a blood pressure assessment? Palpate the brachial artery The nurse measures the blood pressure of a supine patient at 110/70 mm Hg. When the patient stands, the nurse immediately finds the blood pressure to be 90/70 mm Hg. The nurse explains these results to the patient using which pathophysiology? Increased peripheral vasodilation Rationale: The abrupt peripheral vasodilation decreases
the force of blood flow in the blood Which clinical manifestation reported by the patient would lead the nurse to obtain orthostatic blood pressure readings? Dizziness with position changes Which action by the nurse during a blood pressure assessment will lead to a falsely high diastolic reading? Deflating blood pressure cuff too slowly Rationale: A falsely high diastolic reading can occur when the blood pressure cuff is deflated too When auscultating the blood pressure of a 2-year-old patient, which is most important for the nurse to perform to obtain an accurate measurement? Have child seated 5 minutes before auscultation The nurse measures the oral temperature of a patient and then learns the patient just drank a cup of iced coffee. Which action by the nurse is appropriate? Asking the patient to return to the clinic in 15 minutes and to refrain from drinking anything The nurse attempts to determine the patient's oxygen saturation level, but the pulse oximeter is not providing a reading. Which assessment finding is likely the cause of the error? Dark nail polishLow blood pressure Rationale: Dark nail polish can prevent accurate readings for pulse oximetry. Hypothermia, vasoconstriction as with hypertension, and low hemoglobin cause inaccurate readings. Sets found in the same folderEAQ Ch: 1022 terms lippy415 Health Assessment-Chapter 9-General Survey & Measu…30 terms monyprak23 EAQ CH: 940 terms lippy415 Health Assessment-Chapter 11-Pain Assessment20 terms monyprak23 Other sets by this creatorEmergency Neurological Life Support (ENL…27 terms Bela_415 HESI 4 REVIEW - CRITICAL CARE - MCA 3167 terms Bela_415 EAQ 2 - RESP. FAILURE, ARDS,VENTILATOR50 terms Bela_415 EAQ 1 - MED SURG 3 / MCA III - CARDIAC50 terms Bela_415 Recommended textbook solutions Clinical Reasoning Cases in Nursing7th EditionJulie S Snyder, Mariann M Harding 2,512 solutions
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Which is the best site for a nurse to measure body temperature in an unconscious patient?Place the thermometer in the axilla (armpit). Place the forearm across the chest and ensure the upper arm is resting against the patient's side. Leave the thermometer in place for 5 minutes. This will ensure that the reading will be accurate.
Which tympanic body temperature is acceptable for adults?Definitions: Normal body (tympanic) temperature: 36.8 ± 0.7°C (98.2F ± 1.3F) 37.5°C is the upper limit of normal for teenagers and adults. Fever: body temperature >37.5°C (99.5F)
When using a tympanic membrane thermometer The first step is to?For an adult or older child, gently pull the helix up and back to visualize the ear canal. For an infant or younger child (under 3), gently pull the lobe down. The probe is inserted just inside the opening of the ear. Never force the thermometer into the ear and do not occlude the ear canal (OER #1).
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In which patient would the tympanic membrane be used as a site for temperature measurement Quizlet
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