Chapter 11: Vital Signs My Nursing Test Banks

Chapter 11: Vital Signs

Cooper and Gosnell: Foundations and Adult Health Nursing, 7th Edition

MULTIPLE CHOICE

1.What part of the body maintains a balance between heat production and heat loss, regulating body temperature?

a. Thymus
b. Thyroid
c. Hypothalamus
d. Adrenal glands

ANS: C

Body temperature is regulated by the hypothalamus.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 257

OBJ: 9 | 13 TOP: Vital signs KEY: Nursing Process Step: N/A

MSC:NCLEX: N/A

2.What type of body temperature remains relatively constant?

a. Surface
b. Rectal
c. Oral
d. Core

ANS: D

The core body temperature remains relatively constant.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 257

OBJ: 2 TOP: Vital signs KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

3.The nurse uses cooling techniques to keep the body temperature below 105 F. What can result from an elevated temperature?

a. Excessive thirst
b. Excessive perspiration
c. Damage to body cells
d. Increased heart rate

ANS: C

If the temperature exceeds 105 F, normal body cells may be damaged.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 258

OBJ: 8 TOP: Vital signs KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

4.The emergency department nurse quickly assesses the temperature of an unconscious patient who has been outside all night in below-freezing temperatures. What temperature is the nurse aware of that can lead to death?

a. 95.2 F
b. 93.0 F
c. 93.2 F
d. 90.8 F

ANS: C

Death can occur if the temperature falls below 93.2 F.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 258

OBJ: 9 TOP: Vital signs KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

5.What is the term for a fever that rises and falls but does not return to normal until the patient is well?

a. Constant
b. Intermittent
c. Remittent
d. Elevated

ANS: C

A remittent fever does not return to normal until the patient becomes well.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 258

OBJ:9TOP:Remittent fever

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

6.How should the nurse position the ear pinna when using the tympanic thermometer on a child?

a. Upward and back
b. Parallel
c. Downward and back
d. Upward and forward

ANS: C

Using the tympanic thermometer for a child, the nurse will tug the ear pinna down and back.

PTS: 1 DIF: Cognitive Level: Application REF: Page 262, Skill 11-1

OBJ:3 | 9TOP:Tympanic thermometer for a child

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

7.How should the nurse position the earpieces on a stethoscope to ensure optimum reception?

a. Backward
b. Parallel to the ears
c. Toward the face
d. Downward

ANS: C

To ensure the best reception of sound, place earpieces pointing toward the face.

PTS: 1 DIF: Cognitive Level: Application REF: Page 264

OBJ: 9 | 12 TOP: Vital signs KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

8.What does the nurse use the diaphragm of the stethoscope to best assess?

a. Carotid sounds
b. Lung sounds
c. Vascular sounds
d. Low-pitched sounds

ANS: B

Lung sounds are auscultated by using the diaphragm of the stethoscope.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 265

OBJ:6 | 9TOP:Stethoscope use

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

9.What is the pulsethe expansion and contraction of an artery produced by?

a. Contraction of the right atrium
b. Contraction of the right ventricle
c. Contraction of the left atrium
d. Contraction of the left ventricle

ANS: D

Expansion and contraction of an artery is caused by the ejection of blood from the left ventricle.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 265

OBJ: 4 TOP: Vital signs KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

10.When assessing vital signs on a 40-year-old male, the nurse identifies a pulse rate of 120. What is this pulse interpreted as by the nurse?

a. Normal
b. Bradycardic
c. Arrhythmic
d. Tachycardic

ANS: D

If the pulse is faster than 100 bpm on an adult patient, it is considered to be tachycardic.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 265

OBJ: 5 TOP: Tachycardia KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

11.The patients pulse is below 60. The nurse is aware that the patient is not receiving digoxin. What does the nurse suspect is causing the bradycardia?

a. Low exercise tolerance
b. Unrelieved severe pain
c. Excessive bed rest
d. A prone position

ANS: B

Bradycardia can result from unrelieved severe pain.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 265

OBJ: 5 TOP: Bradycardia KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

12.What site should be selected if a peripheral pulse needs to be assessed quickly?

a. Radial pulse
b. Brachial pulse
c. Carotid pulse
d. Pedal pulse

ANS: C

The carotid site is the best for finding a pulse quickly.

PTS: 1 DIF: Cognitive Level: Application REF: Page 266

OBJ: 5 TOP: Carotid KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

13.What is the term for the exchange of carbon dioxide and oxygen that takes place at the alveolar level?

a. Tachypnea
b. Internal respiration
c. External respiration
d. Bradypnea

ANS: B

Internal respiration is the exchange of gas at the alveolar level.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 269

OBJ:6TOP:Internal respiration

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

14.A patient is suspected of having a cardiac arrhythmia. The nurse is concerned with the findings of an apical rate of 88 and a radial rate of 80. What is the term for the difference between these two rates?

a. Pulse pressure
b. Unequal pulses
c. Pulse deficit
d. Tachycardia

ANS: C

The difference between radial and apical pulses is called a pulse deficit.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Pages 268-269 Box 11-10

OBJ: 5 TOP: Pulse deficit KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

15.The nurse is alarmed when a patient with a severe head injury of the occipital lobe has a respiratory rate of 10 breaths per minute. Where might this finding indicate that there is an injury?

a. Cerebellum
b. Medulla oblongata
c. Cortex
d. Cerebrum

ANS: B

Rate of respiration is controlled by the medulla oblongata.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 270

OBJ:6TOP:Respiratory rate

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

16.The nurse assesses respirations of a patient demonstrating pursed-lip breathing, flared nostrils, and retractions. How will the nurse describe these respirations?

a. Tachypnea
b. Stertorous
c. Dyspnea
d. Cheyne-Stokes

ANS: C

The patient who is using ancillary muscles to breathe is exhibiting dyspnea.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 271

OBJ: 6 TOP: Dyspnea KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

17.A nurse assesses a neonates temperature by using a temporal artery scanner. What intervention should the nurse implement if the neonates temperature is 96 F?

a. Record the findings
b. Notify the physician
c. Check the axillary temperature
d. Check the tympanic temperature

ANS: A

The neonates temperature normally ranges from 96 to 99.5 F (35.5 to 37.5 C). Temperature regulation is labile (unstable) during infancy because of immature physiological mechanisms. Axillary measurement is considered the least accurate method and is used less frequently since the advent of the tympanic membrane thermometer. Tympanic thermometer readings are suitable for patients of all ages, except infants.

PTS: 1 DIF: Cognitive Level: Application REF: Page 258, Box 11-4

OBJ: 8 TOP: Vital signs KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

18.A nurse assesses a neonates temperature by using a temporal artery scanner. What intervention should the nurse implement if the neonates temperature is 99.5 F?

a. Record the findings
b. Notify the physician
c. Check the axillary temperature
d. Check the tympanic temperature

ANS: A

The neonates temperature normally ranges from 96 to 99.5 F (35.5 to 37.5 C). Temperature regulation is labile (unstable) during infancy because of immature physiological mechanisms. Axillary measurement is considered the least accurate method and is used less frequently since the advent of the tympanic membrane thermometer. Tympanic thermometer readings are suitable for patients of all ages, except infants.

PTS: 1 DIF: Cognitive Level: Application REF: Page 258, Box 11-4

OBJ: 8 TOP: Vital signs KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

19.A nurse assesses a patients dorsalis pedis pulse. The pulse is difficult to feel and not palpable when only slight pressure is applied. How should the nurse document this finding?

a. Weak pulse
b. Normal pulse
c. Thready pulse
d. Bounding pulse

ANS: C

A thready pulse is difficult to feel and is not palpable when only slight pressure is applied. A weak pulse is somewhat stronger than a thready pulse but not palpable when light pressure is applied. A normal pulse is easily felt but not palpable when moderate pressure is applied. A bounding pulse feels full and springlike even under moderate pressure.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 266, Table 11-3

OBJ: 4 | 15 TOP: Pulses KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

20.A nurse assesses a patients dorsalis pedis pulse. The pulse is not palpable when light pressure is applied. How should the nurse document this finding?

a. Weak pulse
b. Normal pulse
c. Thready pulse
d. Bounding pulse

ANS: A

A thready pulse is difficult to feel and is not palpable when only slight pressure is applied. A weak pulse is somewhat stronger than a thready pulse but not palpable when light pressure is applied. A normal pulse is easily felt but not palpable when moderate pressure is applied. A bounding pulse feels full and springlike even under moderate pressure.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 266, Table 11-3

OBJ: 4 | 15 TOP: Pulses KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

21.A nurse assesses a patients dorsalis pedis pulse. The pulse is easily felt but not palpable when moderate pressure is applied. How should the nurse document this finding?

a. Weak pulse
b. Normal pulse
c. Thready pulse
d. Bounding pulse

ANS: B

A normal pulse is easily felt but not palpable when moderate pressure is applied. A thready pulse is difficult to feel and is not palpable when only slight pressure is applied. A weak pulse is somewhat stronger than a thready pulse but not palpable when light pressure is applied. A bounding pulse feels full and springlike even under moderate pressure.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 266, Table 11-3

OBJ: 4 | 15 TOP: Pulses KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

22.A nurse assesses a patients dorsalis pedis pulse. The pulse feels full and springlike even under moderate pressure. How should the nurse document this finding?

a. Weak pulse
b. Normal pulse
c. Thready pulse
d. Bounding pulse

ANS: D

A bounding pulse feels full and springlike even under moderate pressure. A thready pulse is difficult to feel and is not palpable when only slight pressure is applied. A weak pulse is somewhat stronger than a thready pulse but not palpable when light pressure is applied. A normal pulse is easily felt but not palpable when moderate pressure is applied.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 266, Table 11-3

OBJ: 4 | 15 TOP: Pulses KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

MULTIPLE RESPONSE

23.When instructing a primary caregiver about keeping a daily log of blood pressure readings, what instructions should the nurse include? (Select all that apply.)

a. Take the reading at different times during the day.
b. Apply the cuff approximately 2 inches above the antecubital fossa.
c. If unable to get a reading the first time, immediately reinflate the cuff.
d. Assess pulse with the bell of the stethoscope.
e. Apply the cuff snugly.

ANS: B, E

Readings for a blood pressure log should be taken at the same time every day on the same arm. The cuff should be applied 2 inches above the antecubital fossa and snugly secured. The pulse should be assessed with the diaphragm of the stethoscope. If unable to get a reading the first time, the cuff should be deflated completely and reinflated after several minutes.

PTS: 1 DIF: Cognitive Level: Application REF: Pages 276-278, Skill 11-5

OBJ:7TOP:Blood pressure

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

24.When assessing factors that may influence the patients pulse rate, what should the nurse take into consideration? (Select all that apply.)

a. Age
b. Sex
c. Emotion
d. Temperature
e. Religion

ANS: A, B, C, D

All the options listed can affect the pulse rate except religion.

PTS: 1 DIF: Cognitive Level: Application REF: Page 265

OBJ:5TOP:Influences on pulse rate

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

25.A patient is admitted to a medical surgical unit. What factors will determine how frequently vital signs will be assessed? (Select all that apply.)

a. Desire of the patient
b. Judgment of need by the nurse
c. Discretion of the family
d. Orders of the health care provider
e. Patients condition

ANS: B, D, E

Whether and how frequently vital signs are measured depends on the nurses judgment of need, orders of the health care provider, and patients condition. Desire of the patient and family members cannot override these factors, but can be taken into consideration within reason of these factors.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 254-255, Box 11-2

OBJ:11TOP:Frequency of vital signs measurement

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

26.The home health nurse is preparing to educate a patient regarding electronic self-blood pressure measurement. What information should the nurse provide regarding this procedure? (Select all that apply.)

a. Expect precise values
b. Proper measurement techniques are necessary
c. Cuff fits over clothing
d. Stethoscope is not required
e. Recalibration is not necessary

ANS: B, C, D

Self-blood pressure monitoring requires proper measurement techniques, cuff is made to fit over clothing, and stethoscopes are not required. Values may be inaccurate and recalibration is necessary at least once a year.

PTS: 1 DIF: Cognitive Level: Application REF: Pages 278-279

OBJ:14TOP:Self-Blood Pressure Measurement

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

27.The physician orders daily weights on a patient residing in a long-term care setting. What actions should the nurse implement to assess weight accurately? (Select all that apply.)

a. Weigh patient at the same time each day
b. Schedule weighing immediately after breakfast
c. Encourage patient to void before being weighed
d. Ensure same amount of clothing is worn by patient
e. Calibrate by setting scale at zero after each weight

ANS: A, C, D

Accurate assessment of weight should occur at the same time each day, preferably at 6 AM before breakfast. The patient should be encouraged to void before being weighed and the same amount of clothing should be worn each day. The scale should be calibrated to zero before (not after) each weight is taken.

PTS: 1 DIF: Cognitive Level: Application REF: Page 281-282, Skill 11-6

OBJ:10TOP:Weight measurement

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

COMPLETION

28.The nurse assesses for the fifth vital sign, which is______________.

ANS:

pain

Pain is considered the fifth vital sign.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 253

OBJ:1TOPain as a vital sign

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

29.If a patient has an axillary temperature of 96.2 F, the nurse understands that the true temperature is ______.

ANS:

97.2 F

Axillary temperatures are considered to be 1 F below core temperature.

PTS:1DIF:Cognitive Level: Comprehension

REF: Page 257-259, 261 Skill 11-1 OBJ: 3 TOP: Axillary temperature

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

30.The nurse assesses the blood pressure as 192/86, noting that the patient has a pulse pressure of ________.

ANS:

106

one hundred six

The pulse pressure is the difference between the diastolic and systolic readings.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 273

OBJ:7TOPulse pressure

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

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