Vital Signs

Question 1

The part of the body that maintains a balance between heat production and heat loss, regulating body temperature, is the:

Answer 1

hypothalamus .

Question 2

The type of body temperature that remains relatively constant is the:

Answer 2

The core body temperature remains relatively constant.

Question 3

The nurse uses cooling techniques to keep the body temperature below 105° F because such elevated temperature can:

Answer 3

normal body cells may be damaged.

Question 4

The emergency department nurse quickly assesses the temperature of an unconscious patient who has been outside all night in below-freezing temperatures. The nurse is aware that death can occur if the temperature falls below:

Answer 4

Death can occur if temperature falls below 93.2° F.

Question 5

A fever that rises and falls but does not return to normal until the patient is well is classified as:

Answer 5

remittent.

Question 6

Using the tympanic thermometer for a child, the nurse should pull the ear pinna:

Answer 6

the nurse will tug the ear pinna down and back.

Question 7

To ensure optimum reception from a stethoscope, the nurse should place the earpieces pointing:

Answer 7

place earpieces pointing toward the face.

Question 8

The nurse uses the diaphragm of the stethoscope to best assess:

Answer 8

Lung sounds

They are auscultated by using the diaphragm of the stethoscope.

Question 9

The nurse explains that the pulse—the expansion and contraction of an artery—is produced by contraction of the:

Answer 9

is caused by the ejection of blood from the left ventricle.

Question 10

When assessing vital signs on a 40-year-old male, the nurse identifies a pulse rate of 120. This pulse is:

Answer 10

tachycardia

-If the pulse is faster than 100 beats per minute on an adult patient,

Question 11

The patient’s pulse is below 60. Because the nurse is aware that the patient is not receiving digoxin, the nurse believes that the bradycardia might be caused by:

Answer 11

unrelieved severe pain.

Question 12

If a peripheral pulse needs to be assessed quickly, the nurse should select the

Answer 12

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

Question 13

The exchange of carbon dioxide and oxygen that takes place at the alveolar level is termed:

Answer 13

Internal respiration

is the exchange of gas at the alveolar level.

Question 14

Because a cardiac arrhythmia is suspected, the nurse is concerned with the findings of an apical rate of 88 and a radial rate of 80. The difference between the two rates is termed:

Answer 14

Pulse deficit

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

Question 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 because this may indicate an injury to the:

Answer 15

medulla oblongata.

-Rate of respiration is controlled by the medulla oblongata.

Question 16

The respirations of a patient who is demonstrating pursed-lip breathing, flared nostrils, and retractions are described as:

Answer 16

Dyspnea

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

Question 17

A nurse assesses a neonate’s temperature by using a temporal artery scanner. If the neonate’s temperature is 96 F, the nurse should:

Answer 17

record the findings.
-The neonate’s 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 physiologic mechanisms.

Question 18

A nurse assesses a neonate’s temperature by using a temporal artery scanner. If the neonate’s temperature is 99.5 F, the nurse should:

Answer 18

record the findings.

The neonate’s temperature normally ranges from 96 to 99.5 F (35.5 to 37.5 C). .

Question 19

A nurse assesses a patient’s dorsalis pedis pulse. If the pulse is difficult to feel and not palpable when only slight pressure is applied, the nurse should document this finding as a:

Answer 19

thready pulse

-is difficult to feel and is not palpable when only slight pressure is applied.

Question 20

A nurse assesses a patient’s dorsalis pedis pulse. If the pulse is not palpable when light pressure is applied, the nurse should document this finding as a:

Answer 20

weak pulse

-is somewhat stronger than a thready pulse but not palpable when light pressure is applied.

Question 21

A nurse assesses a patient’s dorsalis pedis pulse. If the pulse is easily felt but not palpable when moderate pressure is applied, the nurse should document this finding as a:

Answer 21

normal pulse.- is easily felt but not palpable when moderate pressure is applied.

Question 22

A nurse assesses a patient’s dorsalis pedis pulse. If the pulse feels full and springlike even under moderate pressure, the nurse should document this finding as a:

Answer 22

bounding pulse.- feels full and springlike even under moderate pressure.

Question 23

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

Answer 23

Apply the cuff approximately 2 inches above the
Apply the cuff snugly.
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 secured snugly. 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.

Question 24

The nurse assesses for the fifth vital sign, which is

Answer 24

Pain, is considered the fifth vital sign.

Question 25

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

Answer 25

97.2° F

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

Question 26

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

Answer 26

106

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

Question 27

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

Answer 27

a. Age
b. Sex
c. Emotion
d. Temperature
e. Physical activity