Exam (elaborations)
Chapter 17. Vital Signs
- Course
- Fundamentals of Nursing Care
- Institution
- Allegany College Of Maryland Somerset Campus
Chapter 17. Vital Signs
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Chapter 17. Vital SignsMultiple Choice
Identify the choice that best completes the statement or answers the question.
1. When asked why pain is considered the sixth vital sign, a nurse explains to a patient that pain
1. Indicates the prescribed pain medication is not sufficient.
2. Is thought to be at the root of all changes in vital signs.
3. Increases the blood pressure to dangerous levels.
4. Is a baseline that allows measurement of slight changes.
2. Upon entering a patient’s room, a nurse decides to check the patient’s vital signs rather than delegate the task.
Which of the following reasons would best justify the nurse’s decision not to delegate the task?
1. The patient has just ambulated to the bathroom.
2. The nurse has a nagging concern that something is not right.
3. The patient is being discharged from the hospital.
4. The patient has a long history of hypertension.
3. A nurse understands that a patient with a history of congestive heart failure has a low cardiac output
resulting from
1. An expected increase in stroke volume.
2. A long history of pain and fatigue.
3. The low blood volume that accompanies congestive heart failure.
4. Weakened and damaged heart muscle.
4. A nurse explains to a patient that blood pressure measures
1. The amount of blood volume within the blood vessels.
2. The amount of resistance within the veins during heart contractions.
3. The amount of force being placed on arteries by blood.
4. The amount of pressure exerted by the veins and arteries on the heart.
5. A nurse expects that the blood pressure will increase in the patient who
1. Avoids caffeine, nicotine, and a sedentary lifestyle.
2. Is in top physical condition.
3. Has an increased blood volume, as happens during pregnancy.
4. Has a history of hypotension.
6. A patient admitted with hypertension asks the nurse what causes blood pressure to elevate. The nurse replies:
1. “A long history of smoking can raise the blood pressure over time.”
2. “Blood pressure often is elevated in Asian races.”
3. “Blood pressure can increase by getting in excess of 6 to 8 hours of sleep every night.”
4. “We’re not sure what factors are involved in raising blood pressure.”
7. A nurse explains to a patient with hypertension that diastolic pressure is a measurement of
1. The amount of force blood places on the arterial walls while the ventricles relax.
2. The amount of force blood places on the arterial walls while the ventricles contract.
3. The amount of force blood places on the arterial walls while both the atria and the
ventricles relax.
4. The amount of force blood places on the arterial walls while both the atria and the
ventricles contract.
, 8. While looking over the chart of an elderly patient, a nurse noted several findings that are to be expected as a
result of long-standing hypertension. One of those findings would be
1. A chest radiograph indicating the possibility of pneumonia.
2. Blood work suggestive of kidney failure.
3. A brain scan ruling out a diagnosis of Alzheimer disease.
4. Blood work ruling out a myocardial infarction, or heart attack.
9. A nurse explains to a patient that it is important to slowly change positions to diminish or eliminate
the symptoms of
1. Essential hypertension.
2. Pulse pressure.
3. Postural hypotension.
4. Pre-hypertension.
10. When asked by a patient’s family how core temperature differs from tympanic temperature, a nurse says:
1. “A tympanic temperature is obtained using sterile technique and is more time consuming.”
2. “Taking the core temperature is more reflective of the environment the internal organs
are being exposed to.”
3. “Obtaining a core temperature far outweighs the benefits of a tympanic
temperature because it is less invasive.”
4. “Taking a tympanic temperature is uncomfortable and more invasive.”
11. After taking a patient’s vital signs, a nurse removes the blankets used to cover the patient because the
patient’s temperature was
1. 100°F axillary.
2. 97.8°F rectal.
3. 99.1°F tympanic.
4. 10B.6°F oral.
12. A patient has told a nurse that she will not use artificial means to prevent pregnancy. The nurse describes
monitoring temperature as a natural method of birth control. The nurse explains to the patient that
ovulation can be identified by an increase in body temperature caused by
1. The release of estrogen.
2. Inflammation in the ovary.
3. An increase in progesterone.
4. Stimulation from ephedrine.
13. A nurse is unable to palpate a patient’s dorsalis pedis pulse. The nurse will next attempt to palpate the
1. Brachial pulse.
2. Carotid pulse.
3. Femoral pulse.
4. Posterior tibialis.
14. While listening to a patient’s apical pulse, a nurse identifies that it is difficult to hear both heart sounds. This
would be charted as:
1. “Heart tones are distinct.”
2. “Heart tones are strong.”
3. “Heart tones are absent.”
4. “Heart tones are muffled.”
15. A nurse, unable to palpate the left pedal pulse on a patient with diabetes, should next
1. Chart: “Unable to palpate left pedal pulse.”
2. Notify the physician that the pulse could not be palpated.
, 3. Use the Doppler to listen for the left pedal pulse.
4. Call the nurse supervisor to report the pedal pulse was zero.
16. A nurse closely monitors a patient with a head injury. Upon assessment of vital signs, the nurse notes changes
indicative of increased intracranial pressure caused by brain swelling. Which changes depict increased
intracranial pressure?
1. Decreased temperature and decreased blood pressure
2. Increased blood pressure, increased temperature, increased respirations, and increased
pulse rate
3. Decreased blood pressure, increased pulse rate, and increased respiratory rate
4. Increased blood pressure, decreased respiratory rate, and decreased pulse rate
17. A nurse explains to a patient’s family that his respirations are faster and deeper than normal because
1. His blood oxygen level indicates hypoxemia.
2. He is using his intercostal muscles to breathe.
3. He has developed an inflammation of the phrenic nerve.
4. He is expelling too much carbon dioxide.
18. A febrile patient’s mother asks the nurse why her daughter’s breathing rate is increased. The nurse replies:
1. “It is normal for the fever to increase her metabolic rate. Because the heart and lungs work
together, you see her breathing speed up along with her heart rate.”
2. “It is quite normal for this to happen, so you can expect her respiratory rate to increase by
8 to 10 respirations per minute for each 1°F elevation in temperature.”
3. “Breathing speeds up when the temperature is elevated to blow off some of the body heat.”
4. “It is rare that respirations are affected by fever. We should be very concerned about this.”
19. Upon checking on a patient, a nurse discovers the patient appeared to experience some shortness of breath
while walking back from the restroom. The nurse determines that the patient may be experiencing
1. Episodes of orthopnea.
2. Cheyne-Stokes respirations.
3. Eupnea.
4. Exertional dyspnea.
20. During auscultation, the nurse hears fine rales in the patient’s lower lobes bilaterally. Fine rales are described
as
1. Noisy, snoring sounds during respirations.
2. Musical or whistling sounds with respirations.
3. A sonorous wheeze upon inspiration.
4. Sounding like hair being rubbed between the thumb and index fingers.
21. The pulse oximeter indicates a patient’s blood oxygen level is 89%. A nurse knows that it is important to
1. Verify the oximeter is placed on a site that has adequate capillary refill.
2. Call the laboratory and order arterial blood gases to get a more accurate oxygen level.
3. Encourage the patient to get out of bed and ambulate more.
4. Let the patient rest quietly to reduce the need for oxygen.
22. While assessing a patient’s pulse, a nurse identifies that the pulse obliterates. This means the pulse
1. Is full and has a bounding quality.
2. Is weak, faint, and not perfusing.
3. Disappears upon palpation.
4. Indicates contractions are perfusing.
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