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DeWit's Fundamental Concepts and Skills for Nursing, 5th Edition By Patricia A. Williams -Test Bank

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Chapter 03: Legal and Ethical Aspects of Nursing Williams: deWit's Fundamental Concepts and Skills for Nursing, 5th Edition MULTIPLE CHOICE 1. A student nurse who is not yet licensed: a. may not perform nursing actions until he or she has passed the licensing examination. b. is not respon...

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Chapter 21: Measuring Vital Signs
Williams: deWit's Fundamental Concepts and Skills for Nursing, 5th Edition

MULTIPLE CHOICE

1. The nurse would anticipate a patient diagnosed with damage to the hypothalamus after
suffering a head injury from a fall to exhibit:
a. a blood pressure elevation.
b. a temperature abnormality.
c. a decrease in pulse rate.
d. depressed respirations.
ANS: B
The hypothalamus, which is located between the cerebral hemispheres, controls body
temperature. Any damage to the hypothalamus prevents the body from regulating its
temperature.

DIF: Cognitive Level: Comprehension REF: p. 344 OBJ: Theory #1
TOP: Vital Signs: Temperature KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

2. The nurse documents vital signs on a newly admitted patient as: “blood pressure is 148/94
mm Hg, the pulse is 80 beats/min, and the respirations are 16 breaths/min.” The nurse would
record the pulse pressure as:
a. 14 mm Hg.
b. 54 mm Hg.
c. 64 mm Hg.
d. 80 mm Hg.
ANS: B
In calculating pulse pressure, take the difference between the systolic and diastolic pressures
(ie, 148 – 94 = 54).

DIF: Cognitive Level: Analysis REF: p. 364
OBJ: Clinical Practice #4 TOP: Vital Signs: Blood Pressure
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

3. A patient has been admitted with hypothermia after lying unconscious overnight in an
unheated apartment. The most appropriate route to assess the patient’s core temperature
would be:
a. rectal.
b. tympanic arterial thermometer.
c. axillary.
d. tympanic.
ANS: D

, The same blood vessels serve the hypothalamus and the tympanic membrane, so the
tympanic temperature is an excellent indicator of core body temperature, although it can be
affected by ear wax.

DIF: Cognitive Level: Application REF: p. 348
OBJ: Theory #3 | Clinical Practice #1 TOP: Vital Signs: Temperature
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

4. The nurse would document a patient as being febrile if the patient’s temperature was over:
a. 99.5° F
b. 99.8° F
c. 100° F
d. 100.5° F
ANS: D
A patient with a temperature above the normal range (100.2° F) is called febrile.

DIF: Cognitive Level: Knowledge REF: p. 349 OBJ: Theory #3
TOP: Vital Signs: Temperature KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

5. To ensure an accurate reading when using a glass oral thermometer, it is necessary to:
a. rinse the thermometer with water.
b. wipe the thermometer with alcohol.
c. shake down the galinstan alloy to below normal.
d. dry the thermometer with a dry cotton ball.
ANS: C
Oral thermometers remain at the last reading until they are shaken down; therefore, for
accuracy, the thermometer must be below normal range before using.

DIF: Cognitive Level: Application REF: p. 351
OBJ: Clinical Practice #1 TOP: Vital Signs: Temperature
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

6. The nurse taking an apical pulse would place the stethoscope at:
a. the left of the sternum at the third intercostal space.
b. directly below the sternum.
c. slightly above the left nipple.
d. the left midclavicular line at the fifth intercostal space.
ANS: D
The apical pulse is determined by placing a stethoscope on a point midway between the
imaginary line running from the midclavicle through the left nipple in the fifth intercostal
space.

DIF: Cognitive Level: Application REF: p. 359| Skill 21-4
OBJ: Theory #2 | Clinical Practice #2 TOP: Vital Signs: Pulse

, KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

7. The nurse would record a pulse as bradycardic if the rate were:
a. 64 beats/min.
b. 62 beats/min.
c. 60 beats/min.
d. 59 beats/min.
ANS: D
Bradycardia indicates a slow pulse that is less than 60 beats/min.

DIF: Cognitive Level: Comprehension REF: p. 373 OBJ: Theory #3
TOP: Vital Signs: Pulse KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

8. The nurse is aware that the use of an oral glass thermometer would be contraindicated in a:
a. 5-year-old with a facial laceration.
b. 12-year-old patient with a recent seizure.
c. 15-year-old with an abscessed tooth.
d. 20-year-old with severe dehydration.
ANS: B
The rectal method is best for patients who have seizure activity so as not to put them at risk
for biting and breaking the thermometer.

DIF: Cognitive Level: Application REF: p. 349
OBJ: Clinical Practice #1 TOP: Vital Signs: Temperature
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

9. The nurse anticipates that if the stroke volume of a patient is reduced, the pulse will be:
a. stronger.
b. weaker.
c. bradycardic.
d. irregular.
ANS: B
A weak pulse will result if the stroke volume is reduced, because this decreases circulating
volume.

DIF: Cognitive Level: Comprehension REF: p. 345 OBJ: Theory #2
TOP: Vital Signs: Pulse KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

10. When caring for a victim with a gunshot wound to the abdomen who has lost a significant
amount of blood, the nurse would anticipate the vital signs to reflect:
a. increase in temperature.
b. decrease in blood pressure.
c. decrease in pulse.

, d. decrease in respirations.
ANS: B
If blood volume decreases, as with bleeding, blood pressure decreases.

DIF: Cognitive Level: Analysis REF: p. 347 OBJ: Theory #2
TOP: Vital Signs: Blood Pressure KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

11. When a frail 83-year-old patient whose temperature was 96.8° F at 8:00 AM shows a
temperature of 98.6° F at 4:00 PM, the nurse is:
a. pleased that the temperature has come up to normal.
b. satisfied that the patient is warm enough.
c. concerned about the evidence of fever.
d. relieved that the patient is improving.
ANS: C
In older patients who have a frail frame, the normal temperature is often 97.2° F. An
elevation of 2° F is indicative of fever.

DIF: Cognitive Level: Application REF: p. 349 OBJ: Theory #4
TOP: Vital Signs in the Older Adult KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

12. A patient who is terminally ill is described during shift report as having Cheyne-Stokes
breathing. On assessment, the nurse anticipates finding:
a. a breathing pattern of dyspnea followed by a short period of apnea.
b. rapid wheezing respirations for two or three breaths with short periods of apnea.
c. quick shallow respirations with long periods of apnea.
d. respirations gradually decreasing in rate and depth.
ANS: A
Cheyne-Stokes respirations are faster and deeper rather than slower and are followed by a
period of no breathing.

DIF: Cognitive Level: Analysis REF: p. 363 OBJ: Theory #5
TOP: Vital Signs: Respirations KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

13. The nurse explains to a patient that the pulse oximeter can measure the arterial oxygen by:
a. assessing the amount of blood passing through the sensor.
b. assessing the relative warmth of the skin on the monitored part.
c. measuring the oxygenated hemoglobin through a capillary bed.
d. measuring the respirations to the blood pressure via infrared rays.
ANS: C
The pulse oximeter measures oxygen saturation by means of a sensor/probe attached to
peripheral digits, an earlobe, the nose, or the forehead as it passes through the capillary bed.
Oxygenated blood absorbs more infrared than red light.

DIF: Cognitive Level: Comprehension REF: p. 364 OBJ: Theory #5

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