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Berman/Snyder, Test Bank for Skills in Clinical Nursing 8th Edition
Chapter 2
Question 1
Type: MCSA
The client has an elevated temperature. Which statement is the most clinically appropriate for the nurse to use
when documenting this finding in the medical record?
1. The client is fever.
2. The client is febrile.
3. The client is hyperpyrexia.
4. The client is hyperthermia.
Correct Answer: 2
Rationale 1: The client is febrile. The client has a fever, hyperpyrexia, and hyperthermia.
Rationale 2: The client is febrile. The client has a fever, hyperpyrexia, and hyperthermia.
Rationale 3: The client is febrile. The client has a fever, hyperpyrexia, and hyperthermia.
Rationale 4: The client is febrile. The client has a fever, hyperpyrexia, and hyperthermia.
Global Rationale: The client is febrile. The client has a fever, hyperpyrexia, and hyperthermia.
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
QSEN Competencies: II.B.3. Base individualized care plan on client values, clinical expertise, and evidence
AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research
NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe
client care
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: Define the key terms used in the skills of measuring vital signs.
Page Number: p. 26
Question 2
Type: MCSA
The nurse assesses the client in respiratory distress and notes that the client has see-saw respirations with the chest
and abdomen alternately rising, blue discoloration of the fingertips, and noisy difficult respirations. How would
the nurse describe the client's condition when calling the health care provider?
Berman/Snyder, Test Bank for Skills in Clinical Nursing 8th Edition
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1. Client is tachypneic with costal breathing and cyanosis.
2. Client is bradycardic with diaphragmatic breathing and cyanosis.
3. Client is demonstrating diaphragmatic breathing, and is dyspneic and cyanotic.
4. Client is demonstrating diaphragmatic breathing with audible Korotkoff's sounds.
Correct Answer: 3
Rationale 1: The use of the abdominal muscles for respiration indicates diaphragmatic breathing. The difficult
respirations would be described as dyspnea, and the blue discoloration of the fingertips is cyanosis. The client's
respiratory rate is unknown, so she cannot be described as tachypneic. Bradycardia is a slow heart rate, and the
client's pulse is unknown.
Rationale 2: The use of the abdominal muscles for respiration indicates diaphragmatic breathing. The difficult
respirations would be described as dyspnea, and the blue discoloration of the fingertips is cyanosis. The client's
respiratory rate is unknown, so she cannot be described as tachypneic. Bradycardia is a slow heart rate, and the
client's pulse is unknown.
Rationale 3: The use of the abdominal muscles for respiration indicates diaphragmatic breathing. The difficult
respirations would be described as dyspnea, and the blue discoloration of the fingertips is cyanosis. The client's
respiratory rate is unknown, so she cannot be described as tachypneic. Bradycardia is a slow heart rate, and the
client's pulse is unknown.
Rationale 4: The use of the abdominal muscles for respiration indicates diaphragmatic breathing. The difficult
respirations would be described as dyspnea, and the blue discoloration of the fingertips is cyanosis. The client's
respiratory rate is unknown, so she cannot be described as tachypneic. Bradycardia is a slow heart rate, and the
client's pulse is unknown.
Global Rationale: The use of the abdominal muscles for respiration indicates diaphragmatic breathing. The
difficult respirations would be described as dyspnea, and the blue discoloration of the fingertips is cyanosis. The
client's respiratory rate is unknown, so she cannot be described as tachypneic. Bradycardia is a slow heart rate,
and the client's pulse is unknown.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
QSEN Competencies: II.B.3. Base individualized care plan on client values, clinical expertise, and evidence
AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research
NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe
client care
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: Define the key terms used in the skills of measuring vital signs.
Page Number: pp. 37-40
Question 3
Berman/Snyder, Test Bank for Skills in Clinical Nursing 8th Edition
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Type: MCSA
The nurse is informed during shift report that the assigned client has a wide pulse pressure, is hypertensive, and
has a pulse deficit. When the nurse enters the client's room, which assessments would the nurse perform in order
to confirm this report?
1. Blood pressure and apical pulse assessments
2. Blood pressure and radial pulse assessment
3. Blood pressure and respiratory rate assessment
4. Blood pressure and radial-apical pulse assessment
Correct Answer: 4
Rationale 1: In order to assess a pulse deficit, defined as a discrepancy between the apical and radial pulse rate,
the nurse must perform an apical–radial pulse assessment. Wide pulse pressure and hypertension would be
assessed by measuring blood pressure.
Rationale 2: In order to assess a pulse deficit, defined as a discrepancy between the apical and radial pulse rate,
the nurse must perform an apical–radial pulse assessment. Wide pulse pressure and hypertension would be
assessed by measuring blood pressure.
Rationale 3: In order to assess a pulse deficit, defined as a discrepancy between the apical and radial pulse rate,
the nurse must perform an apical–radial pulse assessment. Wide pulse pressure and hypertension would be
assessed by measuring blood pressure.
Rationale 4: In order to assess a pulse deficit, defined as a discrepancy between the apical and radial pulse rate,
the nurse must perform an apical–radial pulse assessment. Wide pulse pressure and hypertension would be
assessed by measuring blood pressure.
Global Rationale: In order to assess a pulse deficit, defined as a discrepancy between the apical and radial pulse
rate, the nurse must perform an apical–radial pulse assessment. Wide pulse pressure and hypertension would be
assessed by measuring blood pressure.
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
QSEN Competencies: II.B.3. Base individualized care plan on client values, clinical expertise, and evidence
AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research
NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe
client care
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: Define the key terms used in the skills of measuring vital signs.
Page Number: pp. 36, 40-41
Question 4
Berman/Snyder, Test Bank for Skills in Clinical Nursing 8th Edition
Copyright 2016 by Pearson Education, Inc.
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Type: MCSA
When might it be inappropriate for the nurse to assess a client’s vital signs?
1. When a client has a change in health status
2. Upon admitting the client to the facility
3. Before and after the client ambulates
4. When a terminal client with a do-not-resuscitate order has a change in condition
Correct Answer: 4
Rationale 1: When caring for a terminal client who has a do-not-resuscitate order, the nurse might not need to
assess vital signs when his condition changes if it will not impact the plan of care and death is imminent. In all of
the other situations, vital signs should be measured.
Rationale 2: When caring for a terminal client who has a do-not-resuscitate order, the nurse might not need to
assess vital signs when his condition changes if it will not impact the plan of care and death is imminent. In all of
the other situations, vital signs should be measured.
Rationale 3: When caring for a terminal client who has a do-not-resuscitate order, the nurse might not need to
assess vital signs when his condition changes if it will not impact the plan of care and death is imminent. In all of
the other situations, vital signs should be measured.
Rationale 4: When caring for a terminal client who has a do-not-resuscitate order, the nurse might not need to
assess vital signs when his condition changes if it will not impact the plan of care and death is imminent. In all of
the other situations, vital signs should be measured.
Global Rationale: When caring for a terminal client who has a do-not-resuscitate order, the nurse might not need
to assess vital signs when his condition changes if it will not impact the plan of care and death is imminent. In all
of the other situations, vital signs should be measured.
Cognitive Level: Remembering
Client Need: Physiological Integrity
Client Need Sub: Reduction of Risk Potential
QSEN Competencies: II.B.3. Base individualized care plan on client values, clinical expertise, and evidence
AACN Essential Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic,
and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches
NLN Competencies: Context and Environment: Health promotion/disease prevention
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: Identify the indications for measuring and assessing:
a. Temperature.
b. Pulse.
c. Respirations.
d. Blood pressure.
e. Oxygen saturation.
Page Number: pp. 21-22
Berman/Snyder, Test Bank for Skills in Clinical Nursing 8th Edition
Copyright 2016 by Pearson Education, Inc.
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Berman/Snyder, Test Bank for Skills in Clinical Nursing 8th Edition
Chapter 2
Question 1
Type: MCSA
The client has an elevated temperature. Which statement is the most clinically appropriate for the nurse to use
when documenting this finding in the medical record?
1. The client is fever.
2. The client is febrile.
3. The client is hyperpyrexia.
4. The client is hyperthermia.
Correct Answer: 2
Rationale 1: The client is febrile. The client has a fever, hyperpyrexia, and hyperthermia.
Rationale 2: The client is febrile. The client has a fever, hyperpyrexia, and hyperthermia.
Rationale 3: The client is febrile. The client has a fever, hyperpyrexia, and hyperthermia.
Rationale 4: The client is febrile. The client has a fever, hyperpyrexia, and hyperthermia.
Global Rationale: The client is febrile. The client has a fever, hyperpyrexia, and hyperthermia.
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
QSEN Competencies: II.B.3. Base individualized care plan on client values, clinical expertise, and evidence
AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research
NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe
client care
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: Define the key terms used in the skills of measuring vital signs.
Page Number: p. 26
Question 2
Type: MCSA
The nurse assesses the client in respiratory distress and notes that the client has see-saw respirations with the chest
and abdomen alternately rising, blue discoloration of the fingertips, and noisy difficult respirations. How would
the nurse describe the client's condition when calling the health care provider?
Berman/Snyder, Test Bank for Skills in Clinical Nursing 8th Edition
Copyright 2016 by Pearson Education, Inc.
mynursytest.store
,DOWNLOAD THE Test Bank for Skills in Clinical Nursing 8th Edition Berma
1. Client is tachypneic with costal breathing and cyanosis.
2. Client is bradycardic with diaphragmatic breathing and cyanosis.
3. Client is demonstrating diaphragmatic breathing, and is dyspneic and cyanotic.
4. Client is demonstrating diaphragmatic breathing with audible Korotkoff's sounds.
Correct Answer: 3
Rationale 1: The use of the abdominal muscles for respiration indicates diaphragmatic breathing. The difficult
respirations would be described as dyspnea, and the blue discoloration of the fingertips is cyanosis. The client's
respiratory rate is unknown, so she cannot be described as tachypneic. Bradycardia is a slow heart rate, and the
client's pulse is unknown.
Rationale 2: The use of the abdominal muscles for respiration indicates diaphragmatic breathing. The difficult
respirations would be described as dyspnea, and the blue discoloration of the fingertips is cyanosis. The client's
respiratory rate is unknown, so she cannot be described as tachypneic. Bradycardia is a slow heart rate, and the
client's pulse is unknown.
Rationale 3: The use of the abdominal muscles for respiration indicates diaphragmatic breathing. The difficult
respirations would be described as dyspnea, and the blue discoloration of the fingertips is cyanosis. The client's
respiratory rate is unknown, so she cannot be described as tachypneic. Bradycardia is a slow heart rate, and the
client's pulse is unknown.
Rationale 4: The use of the abdominal muscles for respiration indicates diaphragmatic breathing. The difficult
respirations would be described as dyspnea, and the blue discoloration of the fingertips is cyanosis. The client's
respiratory rate is unknown, so she cannot be described as tachypneic. Bradycardia is a slow heart rate, and the
client's pulse is unknown.
Global Rationale: The use of the abdominal muscles for respiration indicates diaphragmatic breathing. The
difficult respirations would be described as dyspnea, and the blue discoloration of the fingertips is cyanosis. The
client's respiratory rate is unknown, so she cannot be described as tachypneic. Bradycardia is a slow heart rate,
and the client's pulse is unknown.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
QSEN Competencies: II.B.3. Base individualized care plan on client values, clinical expertise, and evidence
AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research
NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe
client care
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: Define the key terms used in the skills of measuring vital signs.
Page Number: pp. 37-40
Question 3
Berman/Snyder, Test Bank for Skills in Clinical Nursing 8th Edition
Copyright 2016 by Pearson Education, Inc.
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,DOWNLOAD THE Test Bank for Skills in Clinical Nursing 8th Edition Berma
Type: MCSA
The nurse is informed during shift report that the assigned client has a wide pulse pressure, is hypertensive, and
has a pulse deficit. When the nurse enters the client's room, which assessments would the nurse perform in order
to confirm this report?
1. Blood pressure and apical pulse assessments
2. Blood pressure and radial pulse assessment
3. Blood pressure and respiratory rate assessment
4. Blood pressure and radial-apical pulse assessment
Correct Answer: 4
Rationale 1: In order to assess a pulse deficit, defined as a discrepancy between the apical and radial pulse rate,
the nurse must perform an apical–radial pulse assessment. Wide pulse pressure and hypertension would be
assessed by measuring blood pressure.
Rationale 2: In order to assess a pulse deficit, defined as a discrepancy between the apical and radial pulse rate,
the nurse must perform an apical–radial pulse assessment. Wide pulse pressure and hypertension would be
assessed by measuring blood pressure.
Rationale 3: In order to assess a pulse deficit, defined as a discrepancy between the apical and radial pulse rate,
the nurse must perform an apical–radial pulse assessment. Wide pulse pressure and hypertension would be
assessed by measuring blood pressure.
Rationale 4: In order to assess a pulse deficit, defined as a discrepancy between the apical and radial pulse rate,
the nurse must perform an apical–radial pulse assessment. Wide pulse pressure and hypertension would be
assessed by measuring blood pressure.
Global Rationale: In order to assess a pulse deficit, defined as a discrepancy between the apical and radial pulse
rate, the nurse must perform an apical–radial pulse assessment. Wide pulse pressure and hypertension would be
assessed by measuring blood pressure.
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
QSEN Competencies: II.B.3. Base individualized care plan on client values, clinical expertise, and evidence
AACN Essential Competencies: III.1. Explain the interrelationships among theory, practice, and research
NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe
client care
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: Define the key terms used in the skills of measuring vital signs.
Page Number: pp. 36, 40-41
Question 4
Berman/Snyder, Test Bank for Skills in Clinical Nursing 8th Edition
Copyright 2016 by Pearson Education, Inc.
mynursytest.store
, DOWNLOAD THE Test Bank for Skills in Clinical Nursing 8th Edition Berma
Type: MCSA
When might it be inappropriate for the nurse to assess a client’s vital signs?
1. When a client has a change in health status
2. Upon admitting the client to the facility
3. Before and after the client ambulates
4. When a terminal client with a do-not-resuscitate order has a change in condition
Correct Answer: 4
Rationale 1: When caring for a terminal client who has a do-not-resuscitate order, the nurse might not need to
assess vital signs when his condition changes if it will not impact the plan of care and death is imminent. In all of
the other situations, vital signs should be measured.
Rationale 2: When caring for a terminal client who has a do-not-resuscitate order, the nurse might not need to
assess vital signs when his condition changes if it will not impact the plan of care and death is imminent. In all of
the other situations, vital signs should be measured.
Rationale 3: When caring for a terminal client who has a do-not-resuscitate order, the nurse might not need to
assess vital signs when his condition changes if it will not impact the plan of care and death is imminent. In all of
the other situations, vital signs should be measured.
Rationale 4: When caring for a terminal client who has a do-not-resuscitate order, the nurse might not need to
assess vital signs when his condition changes if it will not impact the plan of care and death is imminent. In all of
the other situations, vital signs should be measured.
Global Rationale: When caring for a terminal client who has a do-not-resuscitate order, the nurse might not need
to assess vital signs when his condition changes if it will not impact the plan of care and death is imminent. In all
of the other situations, vital signs should be measured.
Cognitive Level: Remembering
Client Need: Physiological Integrity
Client Need Sub: Reduction of Risk Potential
QSEN Competencies: II.B.3. Base individualized care plan on client values, clinical expertise, and evidence
AACN Essential Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic,
and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches
NLN Competencies: Context and Environment: Health promotion/disease prevention
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: Identify the indications for measuring and assessing:
a. Temperature.
b. Pulse.
c. Respirations.
d. Blood pressure.
e. Oxygen saturation.
Page Number: pp. 21-22
Berman/Snyder, Test Bank for Skills in Clinical Nursing 8th Edition
Copyright 2016 by Pearson Education, Inc.
mynursytest.store
