Fundamentals
Cumulative
Final
Questions
And
Answers Which
of
the
following
clients
is
experiencing
an
abnormal
change
in
vital
signs?
A
client
whose
(select
all
that
apply):
1)
Blood
pressure
(BP)
was
132/80
mm
Hg
sitting
and
is
120/60
mm
Hg
upon
standing
2)
Rectal
temperature
is
97.9°F
in
the
morning
and
99.2°F
in
the
evening
3)
Heart
rate
was
76
before
eating
and
is
60
after
eating
4)
Respiratory
rate
was
14
when
standing
and
is
22
after
walking
-
ANS
Answer:
1)
Blood
pressure
(BP)
was
132/80
mm
Hg
sitting
and
is
120/60
mm
Hg
upon
standing
3)
Heart
rate
was
76
before
eating
and
is
60
after
eating
Rationale:
The
BP
change
is
abnormal;
a
BP
change
greater
than
10
mm
Hg
may
indicate
postural
hypotension.
The
change
in
heart
rate
is
abnormal;
heart
rate
usually
increases
slightly
after
eating
rather
than
decreasing.
The
temperatures
are
within
normal
range
for
the
rectal
route,
and
temperature
increases
throughout
the
day.
It
is
normal
to
have
an
increased
respiratory
rate
after
exercise.
Which
of
the
following
clients
has
indications
of
orthostatic
hypotension?
A
client
whose
blood
pressure
is:
1)
118/68
when
standing
and
110/72
when
lying
down
2)
140/80,
HR
82
bpm
when
sitting
and
136/76,
HR
98
bpm
when
standing
3)
126/72
lying
down
and
133/80
when
sitting,
and
reports
shortness
of
breath
4)
146/88
when
lying
down
and
130/78
when
standing,
and
reports
feeling
dizzy
-
ANS
Answer:
4)
146/88
when
lying
down
and
130/78
when
standing,
and
reports
feeling
dizzy
Rationale:
Orthostatic
hypotension
is
a
drop
of
10
mm
Hg
or
more
in
blood
pressure
upon
moving
to
a
standing
position,
with
complaints
of
feeling
dizzy
and/or
faint.
A
client
who
has
experienced
prolonged
exposure
to
the
cold
is
admitted
to
the
hospital.
Which
method
of
taking
a
temperature
would
be
most
appropriate
for
this
client?
1)
Axillary
with
an
electronic
thermometer
2)
Oral
with
a
glass
thermometer 3)
Rectal
with
an
electronic
thermometer
4)
Tympanic
with
an
infrared
thermometer
-
ANS
Answer:
3)
Rectal
with
an
electronic
thermometer
Rationale:
The
rectal
route
is
the
most
accurate
for
assessing
core
temperature,
especially
when
it
is
critical
to
get
an
accurate
temperature.
Therefore,
in
this
situation
it
is
preferred.
Temperature
is
a
particularly
relevant
data
point
for
this
client
with
hypothermia
as
it
indicates
the
patient's
baseline
status
and
response
to
treatment.
The
electronic
thermometer
is
safer
than
glass
and
is
relatively
accurate.
Mercury
thermometers
are
no
longer
used
in
the
hospital
setting.
The
accuracy
of
tympanic
thermometers
is
debatable.
Which
of
the
following
clients
would
have
the
most
difficulty
maintaining
thermoregulation?
1)
Young
child
playing
soccer
during
the
summer
2)
Middle-aged
adult
snow
skiing
3)
Young
adult
playing
golf
on
a
hot
day
4)
Older
adult
raking
leaves
on
a
cold
day
-
ANS
Answer:
4)
Older
adult
raking
leaves
on
a
cold
day
Rationale:
Older
adults
have
more
difficulty
maintaining
body
heat
because
of
their
slower
metabolism,
loss
of
subcutaneous
fat,
and
decreased
vasomotor
control.
Falsely
high
blood
pressure
readings
can
be
caused
by
which
of
the
following?
A.
Lying
in
the
supine
position
B.
A
blood
pressure
cuff
that
is
too
small
C.
A
blood
pressure
cuff
that
is
too
large
D.
The
arm
positioned
below
the
level
of
the
heart
-
ANS
Answer:
B.
A
blood
pressure
cuff
that
is
too
small
Rationale:
A
cuff
that
is
too
small
may
cause
an
inaccurately
high
blood
pressure
reading.
The
other
responses
all
can
cause
inaccurately
low
blood
pressure
readings.
Difficulty
breathing
-
ANS
Dyspnea
Pulse
rate
less
than
60
-
ANS
Bradycardia
Affects
both
pulse
&
BP
-
ANS
Autonomic
Nervous
System
Absence
of
respirations
-
ANS
Apnea
Amount
of
air
moving
in
&
out
w/
each
breath
-
ANS
Tidal
volume Body's
thermostat
-
ANS
Hypothalamus
Blood
pressure
greater
than
120/80
-
ANS
Hypertension
Pulse
rate
greater
than
100
-
ANS
Tachycardia
Your
patient
just
finished
a
cup
of
hot
tea.
How
long
will
you
wait
before
taking
her
temperature?
A.
5
minutes
B.
10
minute
C.
15
minutes
D.
30
minutes
-
ANS
Answer:
D.
30
minutes
Which
age
groups
are
most
susceptible
to
thermoregulation
problems,
and
why?
-
ANS
Answer:
Infants
and
older
adults
are
most
susceptible
to
the
effects
of
environmental
temperatures.
Rationale:
Infants
lose
approximately
30%
of
their
body
heat
through
the
head,
which
is
proportionally
larger
with
respect
to
their
body
than
the
heads
of
adults.
Older
adults
have
difficulty
maintaining
body
heat
because
of
decreased
metabolism,
decreased
vasomotor
control,
and
loss
of
subcutaneous
tissue.
List
five
factors
that
affect
body
temperature.
-
ANS
Correct
answers
include
developmental
level,
circadian
rhythm,
environmental
temperature,
gender
(some
students
may
include
hormones),
emotions
and
stress,
stimulation
of
the
sympathetic
nervous
system,
and
increased
production
of
epinephrine
and
norepinephrine.
What
are
the
compensatory
mechanisms
for
decreasing
body
temperature?
-
ANS
Answer:
Peripheral
vasodilation,
sweating,
and
inhibition
of
heat
production
are
mechanisms
that
decrease
body
temperature.
What
are
the
compensatory
mechanisms
for
increasing
body
temperature?
-
ANS
Answer:
Vasoconstriction,
release
of
epinephrine,
and
shivering
are
mechanisms
that
increase
body
temperature.
Piloerection
occurs,
but
it
is
an
important
heat-conservation
reaction
in
hairy
animals,
not
in
humans.
What
four
components
contribute
to
an
individual's
self-concept?
-
ANS
Answer:
Body
image,
role
performance,
personal
identity,
and
self-esteem
contribute
to
an
individual's
self-concept. What
is
self-esteem?
-
ANS
Answer:
Self-esteem
is
one's
emotional
evaluation
of
the
difference
between
one's
ideal
and
actual
self;
that
is,
between
"what
I
think
I
ought
to
be"
and
"what
I
really
am."
What
is
anxiety?
-
ANS
Answer:
Anxiety
is
clinically
defined
as
an
individual's
emotional
response
to
a
stressor
(threat),
even
if
the
precise
stressor
is
unknown.
It
is
characterized
by
a
sense
of
uneasiness,
nervousness,
worrying,
or
fear
and
is
some
times
associated
with
physical
symptoms
such
as
nausea
or
trembling.
Which
nursing
intervention
is
specific
for
promoting
positive
body
image?
1)
Encourage
the
client
to
be
active
and
focus
on
healthy
eating.
2)
Discuss
boundaries,
expectations,
and
management
defined
by
lifestyle
and
family
networks.
3)
Monitor
for
and
discourage
self-doubt
and
self-criticism.
4)
Use
positive
and
reaffirming
language
when
speaking
with
the
patient.
-
ANS
Answer:
1)
Encourage
the
client
to
be
active
and
focus
on
healthy
eating.
Rationale:
Encouraging
the
client
to
be
active
and
focus
on
healthy
eating
is
a
nursing
intervention
that
promotes
positive
body
image.
Discussing
boundaries,
expectations,
and
management
defined
by
lifestyle
and
family
networks
facilitates
role
enhancement.
Monitoring
for
and
discouraging
self-doubt
and
using
positive
and
reaffirming
language
promote
self-esteem.
__________________
is
defined
as
a
loss
of
interest
or
pleasure
in
previously
enjoyed
activities.
1)
Anhedonia
2)
Anxiety
3)
Depression
4)
Ambivalence
-
ANS
Answer:
1)
Anhedonia
Rationale:
Anhedonia
is
defined
as
a
loss
of
interest
or
pleasure
in
previously
enjoyed
activities.
It
is
one
of
the
symptoms
of
depression.
Anxiety
is
defined
as
a
nonspecific
mental
feeling
of
uneasiness
or
apprehension
caused
by
perception
of
threat
to
self.
Depression
is
a
prolonged
feeling
of
sadness;
it
is
associated
with
affective
symptoms
such
as
denial
of
feelings,
anger,
anxiety,
guilt,
helplessness,
hopelessness,
and
sadness,
as
well
as
some
physical
symptoms,
such
as
constipation.
Ambivalence
is
a
feeling
of
uncertainty
or
mental
conflict
about
something
or
is
the
presence
of
two
opposing
ideas
or
emotions
at
the
same
time.
The
nurse
is
evaluating
a
patient's
responses
to
interventions
to
promote
her
self-esteem.
The
patient
has
a
nursing
diagnosis
of
Chronic
Low
Self-Esteem.
The
patient
is
moderately
