Chapter 10: Vital Signs
Physical Examination and Health Assessment, 8th Edition by
Carolyn Jarvis
MULTIPLE CHOICE
1. A patients weekly blood pressure readings for 2 months have ranged between 124/84 mm
Hg and 136/88 mm Hg, with an average reading of 126/86 mm Hg. The nurse knows that
this blood pressure falls within which blood pressure category?
a. Normal blood pressure
b. Prehypertension
c. Stage 1 hypertension
d. Stage 2 hypertension
ANS: B
According to the Seventh Report of the Joint National Committee (JNC 7)
guidelines, prehypertension blood pressure readings are systolic readings of 120 to
139 mm Hg or diastolic readings of 50 to 89 mm Hg.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
2. When assessing an older adult, 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.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Health Promotion and Maintenance
3. Which technique is correct when the nurse is assessing the radial pulse of a patient?
The pulse is counted for:
a. 1 minute, if the rhythm is irregular.
b. 15 seconds and then multiplied by 4, if the rhythm is regular.
c. 2 full minutes to detect any variation in amplitude.
d. 10 seconds and then multiplied by 6, if the patient has no history of cardiac
abnormalities.
, ANS: A
Recent research suggests that the 30-second interval multiplied by 2 is the most
accurate and efficient technique when heart rates are normal or rapid and when
rhythms are regular. If the rhythm is irregular, then the pulse is counted for 1 full
minute.
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
4. When assessing a patients pulse, the nurse should also notice which of these
characteristics?
a. Force
b. Pallor
c. Capillary refill time
d. Timing in the cardiac cycle
ANS: A
The pulse is assessed for rate, rhythm, and force.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
5. 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. The nurses next action would be to:
a. Immediately notify the physician.
b. Consider this finding normal in children and young adults.
c. Check the childs blood pressure, and note any variation with respiration.
d. Document that this child has bradycardia, and continue with the assessment.
ANS: B
Sinus arrhythmia is commonly found in children and young adults. During the
respiratory cycle, the heart rate varies, speeding up at the peak of inspiration and
slowing to normal with expiration.
DIF: Cognitive Level: Analyzing (Analysis)
MSC: Client Needs: Health Promotion and Maintenance
6. When assessing the force, or strength, of a pulse, the nurse recalls that the pulse:
a. Is usually recorded on a 0- to 2-point scale.
b. Demonstrates elasticity of the vessel wall.
c. Is a reflection of the hearts stroke volume.
d. Reflects the blood volume in the arteries during diastole.
ANS: C
The heart pumps an amount of blood (the stroke volume) into the aorta. The force
flares the arterial walls and generates a pressure wave, which is felt in the
Physical Examination and Health Assessment, 8th Edition by
Carolyn Jarvis
MULTIPLE CHOICE
1. A patients weekly blood pressure readings for 2 months have ranged between 124/84 mm
Hg and 136/88 mm Hg, with an average reading of 126/86 mm Hg. The nurse knows that
this blood pressure falls within which blood pressure category?
a. Normal blood pressure
b. Prehypertension
c. Stage 1 hypertension
d. Stage 2 hypertension
ANS: B
According to the Seventh Report of the Joint National Committee (JNC 7)
guidelines, prehypertension blood pressure readings are systolic readings of 120 to
139 mm Hg or diastolic readings of 50 to 89 mm Hg.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
2. When assessing an older adult, 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.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Health Promotion and Maintenance
3. Which technique is correct when the nurse is assessing the radial pulse of a patient?
The pulse is counted for:
a. 1 minute, if the rhythm is irregular.
b. 15 seconds and then multiplied by 4, if the rhythm is regular.
c. 2 full minutes to detect any variation in amplitude.
d. 10 seconds and then multiplied by 6, if the patient has no history of cardiac
abnormalities.
, ANS: A
Recent research suggests that the 30-second interval multiplied by 2 is the most
accurate and efficient technique when heart rates are normal or rapid and when
rhythms are regular. If the rhythm is irregular, then the pulse is counted for 1 full
minute.
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
4. When assessing a patients pulse, the nurse should also notice which of these
characteristics?
a. Force
b. Pallor
c. Capillary refill time
d. Timing in the cardiac cycle
ANS: A
The pulse is assessed for rate, rhythm, and force.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
5. 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. The nurses next action would be to:
a. Immediately notify the physician.
b. Consider this finding normal in children and young adults.
c. Check the childs blood pressure, and note any variation with respiration.
d. Document that this child has bradycardia, and continue with the assessment.
ANS: B
Sinus arrhythmia is commonly found in children and young adults. During the
respiratory cycle, the heart rate varies, speeding up at the peak of inspiration and
slowing to normal with expiration.
DIF: Cognitive Level: Analyzing (Analysis)
MSC: Client Needs: Health Promotion and Maintenance
6. When assessing the force, or strength, of a pulse, the nurse recalls that the pulse:
a. Is usually recorded on a 0- to 2-point scale.
b. Demonstrates elasticity of the vessel wall.
c. Is a reflection of the hearts stroke volume.
d. Reflects the blood volume in the arteries during diastole.
ANS: C
The heart pumps an amount of blood (the stroke volume) into the aorta. The force
flares the arterial walls and generates a pressure wave, which is felt in the
