Chapter 26: Vital Signs

A nurse takes a patients vital signs. Which of the following is considered a vital sign?

A) mental status

B) visual acuity

C) blood pressure

D) urinary output

C) blood pressure

Which of the following patients should have their vital signs monitored at least every 4 hours?

A) a patient in a critical care unit

B) a patient hospitalized for high blood pressure

C) a resident in a long-term care facility

D) a long-term care resident on Medicare A

B) a patient hospitalized for high blood pressure

In which of the following situations is it protocol for the nurse to take a patients vital signs? Select all that apply.

A) upon admitting a patient to a hospital

B) at a healthcare screening

C) when medications are given for a cardiac arrhythmia

D) following a diagnostic procedure

E) prior to an invasive procedure

F) when daily medications are dispensed

A) upon admitting a patient to a hospital

B) at a healthcare screening

C) when medications are given for a cardiac arrhythmia

D) following a diagnostic procedure

E) prior to an invasive procedure

A nurse has an order to take the core temperature of a patient. At which of the following sites would a core body temperature be measured?

A) tympanic

B) oral

C) axillary

D) skin surface

A) tympanic

Which of the following is the primary source of heat in the body?

A) hormones

B) metabolism

C) blood circulation

D) muscles

B) metabolism

A nurse places a fan in the room of a patient who is overheated. This is an example of heat loss related to which of the following mechanisms of heat transfer?

A) evaporation

B) radiation

C) conduction

D) convection

D) convection

Which of the following is an average normal temperature in Centigrade for a healthy adult?

A) oral: 37.0C

B) rectal: 36.5C

C) axillary: 37.5C

D) tympanic: 34.4C

A) oral: 37.0C

What anatomic site regulates the pulse rate and force?

A) thermoregulatory center

B) cardiac sinoatrial node

C) cardiac atria and valves

D) peripheral chemoreceptors

B) cardiac sinoatrial node

A patient is constipated and trying to have a bowel movement. How does holding the breath and pushing down (the Valsalva maneuver) affect the pulse?

A) left ventricle pumps more forcefully; pulse is stronger

B) stimulates the vagus nerve to increase the rate

C) stimulates the vagus nerve to decrease the rate

D) right ventricle is less efficient; pulse is thready

C) stimulates the vagus nerve to decrease the rate

The arterial blood gases for a patient in shock demonstrate increased carbon dioxide and decreased oxygen. What type of respirations would the nurse expect to assess based on these findings?

A) absent and infrequent

B) shallow and slow

C) rapid and deep

D) noisy and difficul

C) rapid and deep

A nurse walks into a patients room and finds him having difficulty breathing and complaining of chest pain. He has bradycardia and hypotension. What should the nurse do next?

A) Take vital signs again in 15 to 30 minutes.

B) Document the data and report it later.

C) Ask the patient if he is anxious or afraid.

D) Report findings to the physician immediately.

D) Report findings to the physician immediately.

Which of the following pathologic conditions would result in release of ADH by the posterior pituitary?

A) hemorrhage

B) allergies

C) obesity

D) asthma

A) hemorrhage

A student is reading the medical record of an assigned patient and notes the patient has been afebrile for the past 12 hours. What does the term afebrile indicate?

A) normal body temperature

B) decreased body temperature

C) increased body temperature

D) fluctuating body temperature

A) normal body temperature

A nurse is assessing a patient who has a fever, has an infection of a flank incision, and is in severe pain. What type of pulse rate would be likely?

A) bradycardia

B) tachycardia

C) dysrhythmia

D) bigeminal

B) tachycardia

While assessing vital signs of a patient with a head injury and increased intracranial pressure (IICP), a nurse notes that the patients respiratory rate is 8 breaths/min. How will the nurse interpret this finding?

A) bradypnea is uncommon in patient with IICP

B) IICP most commonly results in tachypnea

C) bradypnea is a response to IICP

D) this is a normal respiratory rate

C) bradypnea is a response to IICP

A nurse is conducting a health history for a patient with a chronic respiratory problem. What question might the nurse ask to assess for orthopnea?

A) Do you have problems breathing when you walk up stairs?

B) Does your medication help you breathe better?

C) How many pillows do you sleep on at night to breathe better?

D) Tell me about your breathing difficulties since you stopped smoking.

C) How many pillows do you sleep on at night to breathe better?

What population is at greatest risk for hypertension?

A) Hispanic

B) White

C) Asian

D) African American

D) African American

A middle-aged, overweight adult man has had hypertension for 15 years. What pathologic event is he most at risk for?

A) stroke

B) anemia

C) cancer

D) infection

A) stroke

A nurse educator is teaching a patient about a healthy diet. What information would be included to reduce the risk of hypertension?

A) Eat a diet high in fruits and vegetables.

B) Remember to drink 8 to 10 glasses of water a day.

C) It is important to have increased fats in your diet.

D) Put away the salt shaker and eat low-salt foods.

D) Put away the salt shaker and eat low-salt foods.

A nurse is caring for a patient who is ambulating for the first time after surgery. Upon standing, the patient complains of dizziness and faintness. The patients blood pressure is 90/50. What is the name for this condition?

A) orthostatic hypotension

B) orthostatic hypertension

C) ambulatory bradycardia

D) ambulatory tachycardia

A) orthostatic hypotension

What site for taking body temperature with a glass thermometer is contraindicated in patients who are unconscious?

A) rectal

B) tympanic

C) oral

D) axillary

C) oral

A patient has been diagnosed with peripheral vascular disease of the lower extremities. What site would the nurse use to assess circulation of the legs?

A) radial artery

B) dorsalis pedis artery

C) temporal artery

D) carotid artery

B) dorsalis pedis artery

A nurse is taking a patients temperature and wants the most accurate measurement, based on core body temperature. What site should be used?

A) rectal

B) oral

C) axillary

D) forehead

A) rectal

A student nurse assesses a blood pressure on an adult and finds it to be 140/86. What term is used for the top number (140)?

A) systolic pressure

B) diastolic pressure

C) pulse pressure

D) hypotension

A) systolic pressure

A hospital unit has a policy that rectal temperatures may not be taken on patients who have had cardiac surgery. What rationale supports this policy?

A) It is an embarrassing and painful assessment.

B) Thermometer insertion stimulates the vagus nerve.

C) It is less expensive to take oral temperatures.

D) It is to avoid perforating the wall of the rectum.

B) Thermometer insertion stimulates the vagus nerve.

As adults age, the walls of their arterioles become less elastic, increasing resistance and decreasing compliance. How does this affect the blood pressure?

A) The blood pressure does not change.

B) The blood pressure is erratic

C) The blood pressure decreases.

D) The blood pressure increases.

D) The blood pressure increases.

What equipment is needed to take an apical pulse?

A) sphygmomanometer

B) electronic thermometer

C) stethoscope

D) no specific equipment

C) stethoscope

Two nurses collaborate in assessing an apical-radial pulse on a patient. The pulse deficit is 16 beats/min. What does this indicate?

A) The radial pulse is more rapid than the apical pulse.

B) This is a normal finding and should be ignored.

C) The patients arteries are very compliant.

D) Not all of the heartbeats are reaching the periphery.

D) Not all of the heartbeats are reaching the periphery.

A nurse is assessing the blood pressure on an obese woman. What error might occur if the cuff used is too narrow?

A) reading is erroneously high

B) reading is erroneously low

C) pressure on the cuff with be painful

D) it will be difficult to pump up the bladder

A) reading is erroneously high

Various sounds are heard when assessing a blood pressure. What does the first sound heard through the stethoscope represent?

A) systolic pressure

B) diastolic pressure

C) auscultatory gap

D) pulse pressure

A) systolic pressure

An adult patient is assessed as having an apical pulse of 140. How would the nurse document this finding?

A) bradycardia

B) tachycardia

C) dysrhythmia

D) normal pulse

B) tachycardia

A patient in a physicians office has a single blood pressure (BP) reading of 150/92. Should the patient be taught about hypertension?

A) It depends on the time of day the BP was taken.

B) It depends on whether the patient is male or female.

C) No, a single BP reading should not be used.

D) Yes, this reading is high enough to be significant.

C) No, a single BP reading should not be used.

All of the following patients have a body temperature of 38C (100.4F). About which patient would a nurse be most concerned?

A) an older adult

B) a pregnant adolescent

C) a junior high football player

D) a 2-month-old infant

D) a 2-month-old infant

A home healthcare nurse notices that his assigned patient uses a mercury thermometer. He asks the nurse what to do if it breaks. Which of the following is not correct?

A) Just flush the glass and mercury down the toilet.

B) Do not vacuum the area where it breaks.

C) Open the windows and close off the room for an hour.

D) Throw away any clothing exposed to the mercury.

A) Just flush the glass and mercury down the toilet.