Chapter 6 Vital Signs & Pain

Question 1

The pyrexia response is triggered by the production and release of
a. prostaglandins.
b. endogenous pyrogens.
c. hypothalamic enzymes.
d. thyroid hormones.

Answer 1

ANS: A
When microorganisms invade the body, pyrogens are released and travel to the hypothalamus.
The pyrexia response is then triggered by the production and release of prostaglandins.

Question 2

During expiration, the internal intercostals
a. increase the force of muscular contraction.
b. decrease the lateral diameter during expiration.
c. decrease the intrathoracic space.
d. increase elastic recoil during expiration.

Answer 2

ANS: B
The diaphragm is the dominant muscle during respiration. It contracts and pushes downward
during inspiration to increase the intrathoracic space. The external intercostal muscles increase
the AP diameter during inspiration and the internal intercostals decrease the lateral diameter
during expiration.

Question 3

The fifth vital sign is
a. pain.
b. orientation.
c. waist-to-hip ratio.
d. body mass index (BMI).

Answer 3

ANS: A
Pain, the universal distress signal, is now recognized as the fifth vital sign.

Question 4

The Joint Commission (TJC) requires that
a. pain be assessed on all discharges.
b. repeated assessment of pain be limited to those patients who complain of pain.
c. repeated intensity documentation be made of the course of pain relief for all
patients.
d. pain be assessed on surgical patients.

Answer 4

ANS: C
TJC requires pain assessment on all admissions, repeated assessments for pain regardless of
the initial complaint or surgical experience, and repeated intensity documentation of the
course of pain relief for all patients.

Question 5

The perception of pain
a. is the same across cultures.
b. can be easily assessed in neonates.
c. is predictable with the same circumstances.
d. is affected by emotions and quality of sleep.

Answer 5

ANS: D
The perception of pain is variable and is affected by emotions, cultural background, sleep
deprivation, previous pain experience, and age. Perception of pain is different among different
cultures. Neonates do feel pain, but perception of pain cannot be assessed in neonates. Each
circumstance will provide different pain perception.

Question 6

The most frequent cause of serious hypertension in children is
a. heart disease.
b. liver failure.
c. renal disease.
d. rheumatic fever

Answer 6

ANS: C
If the systolic blood pressure is elevated and the diastolic blood pressure is not, anxiety may
be responsible. Blood pressure in children varies by gender and height at any age.
Hypertension in children is becoming more common because of the increased prevalence of
overweight children. Usually, hypertension is caused by kidney disease, renal arterial disease,
coarctation of the aorta, and pheochromocytoma, not heart disease, liver failure, or rheumatic
fever.

Question 7

Underestimation of blood pressure will occur if the cuff’s width covers
a. less than half of the upper arm.
b. less than 5 inches of the lower arm.
c. more than two-thirds of the upper arm.
d. more than 4 inches of the lower arm.

Answer 7

ANS: C
Cuffs that are too wide will underestimate blood pressure, which would occur with a cuff that
covers more than two-thirds of the upper arm.

Question 8

Which pulse characteristic in the neonate may indicate infection?
a. Bounding pulse rate
b. Regular pulse rate
c. Sustained high pulse rate
d. Intermittent slow pulse rate

Answer 8

ANS: C
Sustained tachycardia in a neonate may be the first indication of infection.

Question 9

Infants delivered by Cesarean section demonstrate which respiratory characteristic in
comparison to infants delivered vaginally?
a. Slower respiratory rate
b. Faster respiratory rate
c. Shallower respirations
d. Deeper respirations

Answer 9

ANS: B
Infants delivered by Cesarean section may have a more rapid respiratory rate than babies
delivered vaginally.

Question 10

Which occurs with malignant hypertension? (Select all that apply.)
a. Blurred vision
b. Sleep disturbance
c. Tachycardia
d. Dyspnea
e. Encephalopathy

Answer 10

ANS: A, D, E
Signs of malignant hypertension include headache, blurred vision, dyspnea, and
encephalopathy.

Question 11

In a syndrome in which regional pain extends beyond this specific peripheral nerve injury,
you would notice which of the following? (Select all that apply.)
a. Allodynia
b. Sleep disturbance
c. Blood flow changes
d. Numbness
e. Edema

Answer 11

ANS: A, C, D, E
Complex regional pain syndrome includes the following symptoms: burning shooting pain
with aching character, exaggerated sensitivity to cold, allodynia, numbness, edema, blood
flow changes, and temperature changes.