Deck 4: Vital Signs and Pain Assessment

Question 1

The value of the use of scales for patients to rate their pain intensity is that

A)the emotional responses are factored in.
B)correlation with others' expectations is achieved.
C)the patient's response to therapy can be documented.
D)subjective responses are eliminated.
E)the patient's perception is minimized.

Answer 1

the patient's response to therapy can be documented.

Question 2

The heart rate of a pregnant woman may increase to a level at term that is _____ higher than normal.

A)5% to 10%
B)10% to 30%
C)40% to 60%
D)60% to 80%
E)80% to 100%

Answer 2

10% to 30%

Question 3

The fifth vital sign is

A)pain.
B)orientation.
C)waist-to-hip ratio.
D)body mass index (BMI).
E)weight.

Answer 3

pain.

Question 4

Which of the following make infants more susceptible to hypothermia?

A)Low body surface area for weight
B)Thicker skin
C)Limited ability to cope with cold stress
D)Higher pulse rate
E)Lower blood pressure

Question 5

Your 85-year-old patient is complaining of right knee pain. She has a history of osteoarthritis for which she is given antiinflammatory medication. To assess her right knee pain, you should ask her if

A)the current pain is similar to previous pain.
B)the left knee hurts as well.
C)she took pain medication last night.
D)the pain gets better when she sits.
E)this is the worse pain she has ever had.

Question 6

Hypertension in a pregnant woman (blood pressure reading greater than or equal to 160 mm Hg systolic or 110 mm Hg diastolic) is one sign of

A)a normal pregnancy.
B)a nulliparous woman.
C)preeclampsia.
D)a multiparous woman.
E)Braxton Hicks contractions.

Question 7

Which of the following groups has the greatest variation in pulse rate?

A)Toddlers
B)Premature infants
C)Neonates
D)Adolescents
E)Older adults

Question 8

Which of the following is most closely related to damage or dysfunction of the central or peripheral nervous system?

A)Chronic pain
B)Neuropathic pain
C)Acute pain
D)Acute inflammation
E)Surgery

Question 9

Which of the following is not related to older adults underreporting pain?

A)They believe it is a normal part of aging.
B)They have a diminished perception of pain.
C)They do not want to be a nuisance.
D)They believe reporting pain will lead to expensive testing or hospitalization.
E)They are hesitant to take pain medications.

Question 10

Which is the most reliable indicator of a patient's pain?

A)Facial grimacing
B)Grunting or groaning
C)Body movements
D)Reluctance to be moved
E)Patient's report of the pain

Question 11

Which of the following is not involved in increasing body temperature?

A)Pyrogens
B)Vasoconstriction
C)Shivering
D)Vasodilation
E)Prostaglandins

Question 12

Body temperature is regulated by the

A)thalamus.
B)hypothalamus.
C)medulla.
D)pons.
E)cerebellum.

Question 13

Which pulse is most commonly used to assess heart rate?

A)Radial
B)Brachial
C)Dorsalis pedis
D)Posterior tibial
E)Popliteal

Question 14

A 5-year-old is complaining of nondescriptive "belly pain." Your next action should be to ask him to

A)point a finger to the spot that hurts.
B)draw a circle around the area that hurts.
C)use a metaphor to describe the pain.
D)identify what makes the pain worse.
E)allow him to use a "pain-o-meter."

Question 15

Which of the following is a subjective measurement?

A)Temperature
B)Pulse
C)Blood pressure
D)Pain
E)Respirations

Question 16

The perception of pain:

A)is the same across cultures.
B)does not apply to neonates.
C)is predictable with the same circumstances.
D)is affected by emotions and quality of sleep.
E)is not affected by age.

Question 17

A pain scale that is reliable and valid for children is the _____ scale.

A)pain-o-meter
B)pain-rating instrument
C)numeric pain intensity
D)Wong/Baker Faces Rating
E)descriptive pain intensity

Question 18

Body language that leads you to suspect the person is in pain is

A)talkative, verbose speech.
B)fretful hand movements.
C)focused, fixed eye stares.
D)marked salivation.
E)flushed, dry skin.

Question 19

Nociceptors transmit pain impulses from the periphery along A-delta and C-polymodal fibers to the

A)posterior horn of the spinal cord.
B)hypothalamus.
C)cerebellum.
D)dorsal horn of the spinal cord.
E)pons.

Question 20

During pregnancy, all of the following may be related to back pain except

A)lax pelvic ligaments.
B)weight gain.
C)hyperlordosis.
D)anterior tilt of the pelvis.
E)lower blood pressure.

Question 21

A patient with trigeminal neuralgia would describe the pain as

A)throbbing and dull.
B)burning or shocklike.
C)tender and deep.
D)crushing and tearing.
E)pressure or squeezing.

Question 22

The difference in blood pressure readings between the right and left arms is considered normal up to _____ mm Hg.

A)5
B)10
C)20
D)25
E)30

Question 23

Which pulse is generally used to assess heart rate?

A)Radial
B)Brachial
C)Dorsalis pedis
D)Posterior tibial
E)Popliteal

Question 24

The nurse assesses the blood pressure to be 140/62 mm Hg and records 78 as the

A)pulse pressure.
B)pulse deficit.
C)afterload pressure.
D)preload pressure.
E)stroke volume.

Question 25

A blood pressure cuff bladder should be long enough to

A)cover 25% of the arm circumference.
B)cover 50% of the arm circumference.
C)cover 80% of the arm circumference.
D)completely encircle the arm.
E)wrap around the arm twice.

Question 26

A normal adult's pulse pressure should range from _____ mm Hg.

A)10 to 20
B)20 to 25
C)30 to 40
D)60 to 70
E)80 to 100

Question 27

Blood pressure may increase during the process of aging caused by

A)increasing vagal tone.
B)decreasing cardiac output.
C)diminished tolerance to pain.
D)increasing stiffness of the blood vessels.
E)decreasing vascular resistance.

Question 28

If a sufficiently large cuff is unavailable to fit the arm of an obese person, which technique may be used to assess blood pressure?

A)Wrap a standard cuff around the deltoid area and place the stethoscope over the radial artery.
B)Wrap a standard cuff around the forearm and place the stethoscope over the radial artery.
C)Wrap a standard cuff around the thigh and place the stethoscope on the dorsalis pedis.
D)Wrap a pediatric cuff around the ankle and place the stethoscope on the popliteal artery.
E)Wrap a standard cuff around the forearm and place the stethoscope over the ulnar artery.

Question 29

If only two blood pressure values are recorded, they are the _____ sounds.

A)first systolic and first diastolic
B)first systolic and second diastolic
C)second systolic and first diastolic
D)second systolic and second diastolic
E)first and second diastolic.

Question 30

The most frequent cause of serious hypertension in children is

A)malnutrition.
B)liver failure.
C)renal disease.
D)rheumatic fever.
E)heart disease.

Question 31

Postural hypotension is defined as which of the following when the patient stands compared with a sitting or supine reading?

A)Blood pressure drop of more than 20 mm Hg in systolic and 10 mm Hg drop in diastolic
B)Pulse rate decrease with a systolic pressure increase of at least 15 mm Hg
C)Diastolic pressure increase of more than 5 mm Hg and no pulse rate changes
D)Pulse rate decrease and diastolic pressure decrease of more than 5 mm Hg
E)Decrease in pulse pressure