CCS Health Assessment & Vital Signs 2 — Questions and Answers
Question 1: A client's blood pressure reads 148/92 mmHg on two separate occasions. How should the care specialist categorize this reading?
- Normal blood pressure
- Elevated blood pressure
- Stage 1 hypertension (Correct answer)
- Stage 2 hypertension
Correct answer: Stage 1 hypertension
A reading of 130-139/80-89 mmHg is Stage 1 hypertension; 140-179/90-109 mmHg is Stage 2 hypertension, making 148/92 Stage 2.
Question 2: When assessing skin turgor in an elderly client, the skin on the back of the hand remains tented for 4 seconds. What does this indicate?
- Normal hydration for the client's age
- Possible dehydration (Correct answer)
- Fluid overload
- Normal skin elasticity
Correct answer: Possible dehydration
Prolonged skin tenting (more than 2 seconds) suggests dehydration, though skin turgor assessment is less reliable in older adults due to decreased skin elasticity.
Question 3: A care specialist notes that a client's radial pulse is irregular, with beats skipping unpredictably. What is the most appropriate next action?
- Document it as a normal variation
- Count the apical pulse for a full minute and report findings (Correct answer)
- Recheck the pulse after 5 minutes
- Administer a PRN cardiac medication
Correct answer: Count the apical pulse for a full minute and report findings
An irregular radial pulse warrants assessment of the apical pulse for a full 60 seconds and prompt reporting to the supervising nurse or provider.
Question 4: Which temperature measurement site provides the most accurate core body temperature reading?
- Oral
- Axillary
- Rectal (Correct answer)
- Tympanic
Correct answer: Rectal
Rectal temperature is closest to core body temperature and is considered the most accurate site for measurement.
Question 5: A client who smoked a cigarette 10 minutes ago needs an oral temperature taken. What should the care specialist do?
- Take the temperature immediately, as smoking does not affect oral readings
- Wait 15–30 minutes before taking the oral temperature (Correct answer)
- Switch to an axillary measurement instead
- Document that the temperature could not be assessed
Correct answer: Wait 15–30 minutes before taking the oral temperature
Smoking, eating, drinking, or chewing gum can alter oral temperature readings; waiting 15–30 minutes ensures accuracy.
Question 6: During a head-to-toe assessment, a care specialist observes that a client's nail beds appear bluish. This finding is called:
- Pallor
- Jaundice
- Cyanosis (Correct answer)
- Erythema
Correct answer: Cyanosis
Cyanosis is a bluish discoloration of the skin and mucous membranes caused by inadequate oxygenation of the blood.
Question 7: What is the normal resting respiratory rate range for an adult?
- 8–12 breaths per minute
- 12–20 breaths per minute (Correct answer)
- 20–28 breaths per minute
- 28–36 breaths per minute
Correct answer: 12–20 breaths per minute
A normal adult respiratory rate at rest is 12–20 breaths per minute; rates outside this range may indicate a respiratory problem.
CCS Health Assessment & Vital Signs 2
A client's blood pressure reads 148/92 mmHg on two separate occasions.
How should the care specialist categorize this reading?