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When measuring the vital signs of a 6-month-old infant, which action by the nurse is correct?
- A. Respirations are measured first, followed by pulse and temperature.
- B. Vital signs should be measured as frequently as in an adult.
- C. Procedures are explained to the parent, and the infant is encouraged to handle the equipment.
- D. The nurse should first measure the infant's vital signs before performing a physical examination.
Correct Answer: A
Rationale: When assessing vital signs in a 6-month-old infant, the correct order is to measure respirations first, followed by pulse and temperature. This sequence is important to avoid potential alterations in respiratory and pulse rates caused by factors like crying or discomfort. Measuring the temperature first, especially rectally, may lead to an increase in respiratory and pulse rates, which can skew the results. It is crucial to follow this specific order to obtain accurate baseline values. Therefore, option A is the correct choice. Option B is incorrect as the frequency of measuring vital signs in infants differs based on individual needs rather than being consistently more frequent than in adults. Option C is not directly related to the correct sequence for measuring vital signs in infants. Option D is incorrect because the physical examination typically follows the assessment of vital signs in clinical practice.
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A 4-month-old child is at the clinic for a well-baby checkup and immunizations. Which of these
actions is most appropriate when the nurse is assessing an infant's vital signs?
- A. The infant's radial pulse should be palpated, and the nurse should notice any
fluctuations resulting from activity or exercise. - B. The nurse should auscultate an apical rate for 1 minute and then assess for any
normal irregularities, such as sinus dysrhythmia.
- C. The infant's blood pressure should be assessed by using a stethoscope with a large
diaphragm piece to hear the soft muffled Korotkoff sounds. - D. The infant's chest should be observed and the respiratory rate counted for 1
minute; the respiratory pattern may vary significantly.
Correct Answer: B
Rationale: The nurse auscultates an apical rate, not a radial pulse, with infants and toddlers. The pulse should be
counted by listening to the heart for 1 full minute to account for normal irregularities, such as sinus
dysrhythmia. Children younger than 3 years of age have such small arm vessels; consequently,
hearing Korotkoff sounds with a stethoscope is difficult. The nurse should use either an electronic
blood pressure device that uses oscillometry or a Doppler ultrasound device to amplify the sounds.
An infant's respiratory rate should be assessed by observing the infant's abdomen, not chest, because
an infant's respirations are normally more diaphragmatic than thoracic. The nurse should auscultate
an apical heart rate, not palpate a radial pulse, with infants and toddlers.
A 60-year-old patient has been treated for pneumonia for the past 6 weeks. The patient is seen today in the clinic for an unexplained weight loss of 10 pounds over the last 6 weeks. Which is an appropriate rationale for this patient's weight loss?
- A. Chronic diseases such as hypertension do not usually cause weight loss.
- B. Weight loss is more likely due to underlying medical conditions than unhealthy eating habits.
- C. Unexplained weight loss often accompanies short-term illnesses.
- D. Weight loss is not typically caused by mental health dysfunctions.
Correct Answer: C
Rationale: Unexplained weight loss in a patient with pneumonia could indicate an underlying short-term illness or a chronic condition like endocrine disease, malignancy, depression, anorexia nervosa, or bulimia. Hypertension is not commonly associated with weight loss; it usually leads to weight gain due to fluid retention. Unhealthy eating habits are less likely to explain significant unexplained weight loss over a short period. Mental health dysfunctions can affect appetite but are not typically primary causes of significant unexplained weight loss.
A 75-year-old man with a history of hypertension was recently changed to a new antihypertensive
drug. He reports feeling dizzy at times. How would the nurse evaluate his blood pressure?
- A. Blood pressure and pulse should be recorded in the supine, sitting, and standing
positions. - B. The patient should be directed to walk around the room and his blood pressure
assessed after this activity. - C. Blood pressure and pulse are assessed at the beginning and at the end of the
examination. - D. Blood pressure is taken on the right arm and then 5 minutes later on the left arm.
Correct Answer: A
Rationale: Orthostatic vital signs should be taken when the person is hypertensive or is taking antihypertensive
medications, when the person reports fainting or syncope, or when volume depletion is suspected.
The blood pressure and pulse readings are recorded in the supine, sitting, and standing positions.
The nurse is assessing the vital signs of a 20-year-old marathon runner and documents the following vital signs: temperature"?36°C; pulse"?48 beats per minute; respirations"?14 breaths per minute; blood pressure"?104/68 mm Hg. Which statement is true concerning these results?
- A. The patient is experiencing bradycardia.
- B. These are normal vital signs for a healthy, athletic adult.
- C. The patient's pulse rate is not normal"?no action is required.
- D. The patient's next clinic visit should occur as scheduled.
Correct Answer: B
Rationale: The correct answer is, 'These are normal vital signs for a healthy, athletic adult.' A pulse rate of 48 beats per minute is considered bradycardia in adults, but it is not a concern in well-trained athletes like marathon runners. Bradycardia is a normal physiological response to aerobic conditioning. Tachycardia, on the other hand, is defined as a pulse rate above 100 beats per minute, which is not the case here. The low pulse rate in this scenario is a reflection of the athlete's cardiovascular fitness. Therefore, there is no need to notify the physician or schedule a follow-up visit based on these findings.
The nurse is assessing an 80-year-old male patient. Which assessment finding would be considered normal?
- A. Decrease in body weight from his younger years
- B. Decrease in deposits of fat in the cheeks and forearms
- C. Presence of kyphosis and flexion in bilateral knees and hips
- D. Change in overall body proportion, including a longer trunk and shorter extremities
Correct Answer: C
Rationale: In an 80-year-old male patient, the presence of kyphosis (rounded upper back) and flexion in bilateral knees and hips are considered normal age-related changes. These postural changes are commonly seen in older adults due to structural changes in the spine and joints. Option A is incorrect as aging individuals typically experience a decrease in body weight, not an increase. Option B is also incorrect as there is usually a decrease in subcutaneous fat from the face and periphery, rather than an increase in fat deposits in specific areas. Option D is incorrect because the change in overall body proportion with aging usually involves a shorter trunk and relatively longer extremities, not the other way around. This is because long bones do not shorten with age, leading to this characteristic change in body proportions.