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Chapter 032

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Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank Chapter 32: Vital Signs MULTIPLE CHOICE 1. A client has developed pneumonia, and his temperature has increased to 37.7° C. The client is shivering and “feels uncomfortable.” The nurse should: 1. Apply hot packs to the axilla and groin 2. Wrap the client’s four extremities 3. Restrict oral fluid consumption 4. Apply a hypothermia mattress ANS: 3 Wrapping the client’s extremities has been recommended to reduce the incidence and intensi
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  Potter & Perry: Fundamentals of Nursing, 7 th  Edition Test Bank Chapter 3: !ital igns#$%TP%E C'(CE 1.A client has developed pneumonia, and his temperature has increased to 37.7° C. The client is shivering and “feels uncomfortable.” The nurse should1.Appl! hot pac s to the a#illa and groin$.%rap the client&s four e#tremities 3.'estrict oral fluid consumption(.Appl! a h!pothermia mattress A)*3%rapping the client&s e#tremities has been recommended to reduce the incidence and intensit! of shivering. +ot pac s should not be applied to the client&s a#illa and groin. luids should not be restricted, but increased to replace fluids lost as a result of the fever. +!pothermia blan ets ma! be used to reduce fever, but if the client is alread! shivering, ah!pothermia blan et is not used, as further stimulation of shivering should be avoided.-A'/0245ComprehensionT6)ursing 6rocess Application*C)C8/9: test plan designation 'eduction of 'is 6otential;<ital *igns$.The client comes to the emergenc! department after having been in the sun for an e#tended period of time. The nurse also determines that the client is ta ing a diuretic. +eatstro e is suspected and the nurse observes for1.-iaphoresis$.Confusion3.Temperature of 32 °  C(.-ecreased heart rateA)*$Confusion is a s!mptom of heatstro e, along =ith delirium, nausea, muscle cramps, visual disturbances, and even incontinence. The most important sign of heatstro e is hot, dr! s in, not diaphoresis. <ictims of heatstro e do not s=eat because of severe electrol!teloss and h!pothalamic malfunction. A normal temperature is 32 °  to 3> °  C. %ith heatstro e the client&s bod! temperature ma! reach as high as (0 ° C. The heart rate is increased =ith heatstro e, not decreased.-A'/0745ComprehensionT6)ursing 6rocess Assessment*C)C8/9: test plan designation 'eduction of 'is 6otential;<ital *igns3.A construction =or er is seen in the emergenc! department =ith lo= blood pressure, normal pulse rate, diaphoresis, and =ea ness. These are clinical signs of osb! items and derived items ? $@, $0 b! osb!, nc., an affiliate of /lsevier nc.  Test 4an  1.+eatstro e$.+eat cramp3.+!pothermia(.+eat e#haustionA)*(The client is e#hibiting signs of heat e#haustion e.g., s!mptoms of fluid volume deficitB. f the client =ere e#periencing heatstro e, the client =ould have an increased pulse rate and =ould not be s=eating. uscle cramps are related to heatstro e. The client is not e#hibiting signs consistent =ith heatstro e. The client is not e#hibiting signs of h!pothermia such as shivering, loss of memor!, or c!anosis.-A'/0>45ComprehensionT6)ursing 6rocess -iagnosis*C)C8/9: test plan designation 'eduction of 'is 6otential;<ital *igns(.A 2!earold bo! has Dust eaten a grape popsicle and the nurse is read! to ta e vital signs. An appropriate action =ould be to1.Ta e the rectal temperature$.Ta e the oral temperature as planned3.+ave the child rinse out the mouth =ith =arm =ater (.%ait $ minutes before assessing the oral temperatureA)*(The nurse should =ait $ to 3 minutes before measuring the oral temperature. The nurseshould =ait, rather than measuring the child&s temperature rectall!, as this is not an emergenc! situation. Ta ing the oral temperature at this time =ould result in an inaccurate reading. 'insing the mouth =ith =arm =ater ma! also provide an inaccurate reading of the child&s actual bod! temperature. The nurse should =ait $ minutes and measure the child&s oral temperature.-A'/0145ComprehensionT6)ursing 6rocess 6lanning*C)C8/9: test plan designation 'eduction of 'is 6otential;<ital *igns0.The client is seen in the emergenc! center for heat e#haustion as a result of e#posure. Thenurse anticipates that treatment =ill include1.'eplacement of fluid and electrol!tes$.nitiation of oral antibiotic therap!3.Application of h!pothermia =raps(.Alcohol sponge bathsA)*1The treatment of heat e#haustion includes transporting the client to a cooler environment and restoring fluid and electrol!te balance. Antibiotic therap! is not =arranted. +!pothermia =raps are not used to treat heat e#haustion. Alcohol baths are not recommended. osb! items and derived items ? $@, $0 b! osb!, nc., an affiliate of /lsevier nc. 3$$  Test 4an  -A'/0>45ComprehensionT6)ursing 6rocess 6lanning*C)C8/9: test plan designation 'eduction of 'is 6otential;<ital *igns2.The appropriate site for ta ing the pulse of a $!earold is1.'adial$.Apical3.emoral(.6edalA)*$The brachial or apical pulse is the best site for assessing an infant&s or !oung child&s pulse because other peripheral pulses are deep and difficult to palpate accuratel!. The radial  pulse is not the best site for assessing a $!earold&s pulse. The femoral pulse is not the  best site for assessing a $!earold&s pulse. The pedal pulse is not the best site for assessing a $!earold&s pulse.-A'/0$145ComprehensionT6)ursing 6rocess Assessment*C)C8/9: test plan designation 'eduction of 'is 6otential;<ital *igns7.The client appears to be breathing faster than before. The nurse should1.As the client if he has felt stressful$.+ave the client la! do=n on the bed3.Count the client&s rate of respirations(.6alpate the client&s o=n radial pulseA)*3The first action the nurse should ta e is to assess the client&s respirator! rate. The nurse can then determine if it is =ithin normal limits and =ill be able to compare it to the  previous measurement to determine if the client is breathing faster than before. *tress ma! increase an individual&s respirator! rate. The nurse should first ma e the obDective measurement of the client&s rate. +aving the client la! do=n ma! decrease a client&s respirator! rate, but the nurse should first assess the client before implementing an! nursing measures. The nurse should count the respirator! rate. 4ased on these findings the nurse ma! or ma! not need to ta e the client&s pulse. Assessing the pulse =ill not verif! if the client is breathing faster.-A'/0$@45ComprehensionT6)ursing 6rocess Assessment*C)C8/9: test plan designation 'eduction of 'is 6otential;<ital *igns>.A nurse administers pain medication for a client complaining of pain. The nurse first assesses vital signs and finds them to be as follo=s blood pressure, 13(;@$ mm +gE  pulse, @ beats per minuteE respirations, $2 breaths per minute. The nurse&s most appropriate action is to1.Five the medication osb! items and derived items ? $@, $0 b! osb!, nc., an affiliate of /lsevier nc. 3$3  Test 4an  $.As if the client is an#ious3.Chec the client&s dressing for bleeding(.'echec the client&s vital signs in 3 minutesA)*1The client&s vital signs are consistent =ith the client being in pain. t =ould be safe and appropriate for the nurse to give the pain medication. As ing if the client is an#ious is notthe most appropriate action. The client is not demonstrating signs of shoc e.g., decreased blood pressure, increased pulseB. The most appropriate action is for the nurse toadminister pain medication. 'echec ing =ould not be the most appropriate action. The nurse should medicate the client for pain.-C'/0$@45Anal!sisT6)ursing 6rocess 6lanning*C)C8/9: test plan designation 'eduction of 'is 6otential;<ital *igns@.The client has bilateral casts on the upper e#tremities, so the nurse =ill be measuring the  blood pressure in the leg. The nurse e#pects the diastolic pressure to be1.1 to ( mm +g higher than in the brachial arter!$.$ to 3 mm +g lo=er than in the brachial arter!3.( to 0 mm +g higher than in the brachial arter!(./ssentiall! the same as that in the brachial arter!A)*(%hen measuring the blood pressure in the legs, s!stolic pressure is usuall! higher b! 1 to ( mm +g than that in the brachial arter!, but the diastolic pressure is the same. The s!stolic pressure, not the diastolic pressure, is 1 to ( mm +g higher than that in the  brachial arter!.easurements of $ to 3 mm +g lo=er and ( to 0 mm +g higher are not true statements.-A'/0(245ComprehensionT6)ursing 6rocess /valuation*C)C8/9: test plan designation 'eduction of 'is 6otential;<ital *igns1.An >(!earold client =ith diabetes is admitted for insulin regulation. %hich of the follo=ing blood pressure, pulse, and respiration measurements, respectivel!, is considered to be =ithin the e#pected limits for a client of this ageG1.46 H 13>;>> mm +g, 6 H 2> beats;min, ' H 12 breaths;min$.46 H 1(;0$ mm +g, 6 H 2> beats;min, ' H 3 breaths;min3.46 H 1>;> mm +g, 6 H 11$ beats;min, ' H 10 breaths;min(.46 H 13$;7( mm +g, 6 H @ beats;min, ' H $( breaths;minA)*1 osb! items and derived items ? $@, $0 b! osb!, nc., an affiliate of /lsevier nc. 3$(

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