2026 Update) Health Assessment |
Questions with Verified Answers| Grade A|
100% Correct -Fortis.
Question:
The client has had a fever, ranging from 99.8F orally to 103F orally, over
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the last 24 hours. The clients fever would be classified as
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1)Constant
2)Intermittent
3)Relapsing
4)Remittent?
Answer:
ANS: 4) Remittent
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Remittent fevers fluctuate widely over a 24-hour period. Constant fevers
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stay above normal with only slight fluctuations. Intermittent fevers
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alternate between normal or subnormal temperatures with periods of
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fever. Relapsing fevers alternate between periods of fever and periods of
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normal temperature, each phase lasting 1 to 2 days.
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,Question:
A clients vital signs 4 hours ago were temperature (oral) 101.4F (38.6C),
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heart rate 110 beats/min, respiratory rate 26 breaths/min, and blood
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pressure 124/78 mm Hg. The temperature is now 99.4F (37.4C). Based
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only on the expected relationship between temperature and respiratory
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rate, the nurse might best anticipate the clients respiratory rate to be
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1)16
2)18
3)20
4)22?
Answer:
ANS: 2) 18 i,- i,-
For every degree Fahrenheit (0.6C) the temperature falls, the respiratory
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rate may decrease up to 4 breaths per minute. The clients temperature
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has fallen 2 degrees; multiplied by 4, this is 8. It was 26 breaths/min: 26 8
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= 18 breaths/min. Keep in mind, this is an estimate and would vary
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depending on the patients baseline health, current condition, age, and
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other factors. i,-
Question:
Which one of the following clients would probably have a higher than
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normal respiratory rate? A client who has
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,1) Had surgery and is receiving a narcotic analgesic
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2) Had surgery and lost a unit of blood intraoperatively
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3) Lived at a high altitude and then moved to sea level
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4) Been exposed to the cold and is now hypothermic?
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Answer:
ANS: 2) Had surgery and lost a unit of blood intraoperatively
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A reduction in hemoglobin from blood loss would increase the respiratory
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rate. Narcotics and hypothermia slow the respiratory rate. Going from
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lower altitudes to higher altitudes inhibits oxygen binding, so going to a
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lower altitude would decrease the respiratory rate or have no effect.
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Hypothermia decreases the metabolic rate, so the respiratory rate would
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likely decrease.i,-
Question:
For which of the following adult clients should the nurse make follow-up
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observations and monitor the vital signs closely? A client whose
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1) Resting morning blood pressure is 136/86 while the afternoon BP is
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128/84 mm Hg i,- i,-
2) Oral temperature is 97.9F in the morning and 99.8F in the evening
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3) Heart rate was 76 beats/min before eating and 88 beats/min after
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eating
, 4) Respiratory rate is 16 breaths/min when standing and 18 when lying
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down?
Answer:
ANS: 1) Resting morning blood pressure is 136/86 while the afternoon BP
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is 128/84 mm Hg
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Both the blood pressures would be classified as prehypertension
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according to the JNC 7 Express guidelines. Body temperature normally
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increases during the course of a day. Heart rate increases for several hours
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after eating. Respiratory depth decreases when lying down, so it would be
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normal for the rate would increase; both rates are within normal limits.
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Question:
A client who has been hospitalized for an infection states, The nursing
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assistant told me my vital signs are all within normal limits; that means Im
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cured. The nurses best response would be which of the following?
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1) Your vital signs confirm that your infection is resolved; how do you feel?
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2) Ill let your healthcare provider know so you can be discharged.
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3) Your vital signs are stable, but there are other things to assess.
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4) We still need to keep monitoring your temperature for a while.?
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Answer:
ANS: 3) Your vital signs are stable, but there are other things to assess.
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