A healthy adult patient tells the nurse that he obtained his blood pressure in “one of those quick machines in the mall” and was alarmed that it was 152/7B. He immediately repeated the measurement, and the value was 158/80. His normal BP value ranges from 114/72 to 118/78. The nurse obtains a blood pressure of 116/76. What would account for the blood pressure of 152/72? Select all that apply

Cuff too small on the device

Arm positioned above heart level

Slow inflation of the cuff by the machine

Patient did not remove his long-sleeved shirt

Insufficient time between measurements

Answer and Explanation

Correct Answer : A,D,E

Blood pressure (BP) measurement is a foundational clinical assessment, but its accuracy is highly influenced by technique, cuff size, body position, and external factors.

Rationale for correct answers:

A. Cuff too small on the device: A cuff that is too small for the client’s arm can result in falsely elevated systolic pressure.

D. Patient did not remove his long-sleeved shirt: Taking BP over clothing can interfere with cuff compression and cause falsely high readings, especially thicker or tight sleeves.

E. Insufficient time between measurements: Taking repeat BP readings too soon (e.g., within 1–2 minutes) doesn’t allow time for vascular recovery and can lead to falsely high results.

Rationale for incorrect answers:

B. Arm positioned above heart level: If the arm is above heart level, BP readings tend to be falsely low, not high. To avoid error, the arm should be at heart level.

C. Slow inflation of the cuff by the machine: Slow deflation, not inflation, affects BP accuracy.

Take-home points:

Improper cuff size, measuring over clothing, and not waiting long enough between readings can all cause falsely elevated BP.
BP measurement should be performed with the arm at heart level, cuff directly on skin, and with the correct-sized cuff to ensure accuracy.

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Correct Answer is A

Explanation

Monitoring and interpreting body temperature is a fundamental nursing task used to assess homeostasis, detect infection, and guide treatment decisions. The normal oral temperature range for adults is typically between 3F.5°C to 37.5°C (97.7°F to 99.5°F).

Rationale for correct answer:

A. Fever (also called pyrexia) is defined as a body temperature above the normal range, typically greater than 38°C (100.4°F) when measured orally.

Rationale for incorrect answers:

B. Hypothermia refers to a core body temperature below 35°C (95°F).

C. Hypertension refers to elevated blood pressure, not body temperature.

D. Afebrile means without fever, or having a normal body temperature.

Take-home points:

A temperature above 38°C (100.4°F) is classified as a fever and should be documented accordingly.
Use accurate terminology for vital signs to ensure clear communication and proper follow-up care.

A. An increase in the pulse rate B. A decrease in body temperature C. A decrease in blood pressure D. An increase in respiratory depth

Correct Answer is A

Explanation

Pain, especially severe acute pain like abdominal pain, triggers a sympathetic nervous system (SNS) response, often referred to as the "fight or flight" reaction. This leads to measurable changes in vital signs.

Rationale for correct answer:

A. An increase in the pulse rate: Pain stimulates the sympathetic nervous system, resulting in tachycardia (increased heart rate).

Rationale for incorrect answers:

B. A decrease in body temperature: Pain does not typically cause a drop in temperature. Hypothermia is more likely in shock, exposure, or metabolic disorders-not as a direct result of pain.

C. A decrease in blood pressure: In the early stages of pain, the SNS response often causes a mild increase in blood pressure.

D. An increase in respiratory depth: Acute abdominal pain usually causes patients to take shallow breaths to minimize movement and discomfort (known as splinting).

Take-home points:

Increased heart rate (tachycardia) is a common and expected physiological response to severe pain due to SNS activation.
Nurses must interpret changes in vital signs in the context of the patient's symptoms to detect early signs of deterioration or complications.

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Naxlex Comprehensive Predictor Exams

A nurse assesses an oral temperature for a patient as 38.5°C (10A.3°F). What term would the nurse use to report this temperature?

Correct Answer is A

Explanation

A patient complains of severe abdominal pain. When assessing the vital signs, the nurse would not be surprised to find what assessment?

Correct Answer is A

Explanation

A patient has a blood pressure reading of 130/90 mm Hg when visiting a clinic. What would the nurse recommend to the patient?

According to the JNC’s seventh report, a BP reading of 144/96 would be considered ______.

Prioritize your nursing interventions based on the vital signs.

A 69-year-old woman is admitted with dizziness, confusion, and dyspnea. Which vital sign should not be delegated to trained ancillary personnel?

An 85-year-old client has had a stroke resulting in right-sided facial drooping, difficulty swallowing, and the inability to move self or maintain position unaided. The nurse determines that which sites are most appropriate for taking the temperature? Select all that apply

During admission of an obese patient with heart failure the assistive personnel (AP) reports to the nurse that the blood pressure (BP) is 140/76 on the left arm and 128/72 on the right arm. What actions do you take on the basis of this information? Select all that apply

For a client with a previous blood pressure of 138/74 mmHg and pulse of 64 beats/min, approximately how long should the nurse take to release the blood pressure cuff in order to obtain an accurate reading?