Deck 11: Vital Signs

Question 1

The nurse is alarmed when a patient with a severe head injury of the occipital lobe has a respiratory rate of 10 breaths per minute. Where might this finding indicate that there is an injury?

A) Cerebellum
B) Medulla oblongata
C) Cortex
D) Cerebrum

Answer 1

Medulla oblongata

Question 2

When assessing vital signs on a 40-year-old male, the nurse identifies a pulse rate of 120. What is this pulse interpreted as by the nurse?

A) Normal
B) Bradycardic
C) Arrhythmic
D) Tachycardic

Answer 2

Tachycardic

Question 3

What part of the body maintains a balance between heat production and heat loss, regulating body temperature?

A) Thymus
B) Thyroid
C) Hypothalamus
D) Adrenal glands

Answer 3

Hypothalamus

Question 4

How should the nurse position the ear pinna when using the tympanic thermometer on a child?

A) Upward and back
B) Parallel
C) Downward and back
D) Upward and forward

Question 5

A nurse assesses a patient's dorsalis pedis pulse. The pulse is difficult to feel and not palpable when only slight pressure is applied. How should the nurse document this finding?

A) Weak pulse
B) Normal pulse
C) Thready pulse
D) Bounding pulse

Question 6

The nurse uses cooling techniques to keep the body temperature below 105° F. What can result from an elevated temperature?

A) Excessive thirst
B) Excessive perspiration
C) Damage to body cells
D) Increased heart rate

Question 7

A nurse assesses a neonate's temperature by using a temporal artery scanner. What intervention should the nurse implement if the neonate's temperature is 96° F?

A) Record the findings
B) Notify the physician
C) Check the axillary temperature
D) Check the tympanic temperature

Question 8

A patient is suspected of having a cardiac arrhythmia. The nurse is concerned with the findings of an apical rate of 88 and a radial rate of 80. What is the term for the difference between these two rates?

A) Pulse pressure
B) Unequal pulses
C) Pulse deficit
D) Tachycardia

Question 9

What is the term for a fever that rises and falls but does not return to normal until the patient is well?

A) Constant
B) Intermittent
C) Remittent
D) Elevated

Question 10

A nurse assesses a patient's dorsalis pedis pulse. The pulse is not palpable when light pressure is applied. How should the nurse document this finding?

A) Weak pulse
B) Normal pulse
C) Thready pulse
D) Bounding pulse

Question 11

What site should be selected if a peripheral pulse needs to be assessed quickly?

A) Radial pulse
B) Brachial pulse
C) Carotid pulse
D) Pedal pulse

Question 12

What is the term for the exchange of carbon dioxide and oxygen that takes place at the alveolar level?

A) Tachypnea
B) Internal respiration
C) External respiration
D) Bradypnea

Question 13

What does the nurse use the diaphragm of the stethoscope to best assess?

A) Carotid sounds
B) Lung sounds
C) Vascular sounds
D) Low-pitched sounds

Question 14

What type of body temperature remains relatively constant?

A) Surface
B) Rectal
C) Oral
D) Core

Question 15

The emergency department nurse quickly assesses the temperature of an unconscious patient who has been outside all night in below-freezing temperatures. What temperature is the nurse aware of that can lead to death?

A) 95.2° F
B) 93.0° F
C) 93.2° F
D) 90.8° F

Question 16

How should the nurse position the earpieces on a stethoscope to ensure optimum reception?

A) Backward
B) Parallel to the ears
C) Toward the face
D) Downward

Question 17

A nurse assesses a neonate's temperature by using a temporal artery scanner. What intervention should the nurse implement if the neonate's temperature is 99.5° F?

A) Record the findings
B) Notify the physician
C) Check the axillary temperature
D) Check the tympanic temperature

Question 18

The nurse assesses respirations of a patient demonstrating pursed-lip breathing, flared nostrils, and retractions. How will the nurse describe these respirations?

A) Tachypnea
B) Stertorous
C) Dyspnea
D) Cheyne-Stokes

Question 19

What is the pulse-the expansion and contraction of an artery- produced by?

A) Contraction of the right atrium
B) Contraction of the right ventricle
C) Contraction of the left atrium
D) Contraction of the left ventricle

Question 20

The patient's pulse is below 60. The nurse is aware that the patient is not receiving digoxin. What does the nurse suspect is causing the bradycardia?

A) Low exercise tolerance
B) Unrelieved severe pain
C) Excessive bed rest
D) A prone position

Question 21

The physician orders daily weights on a patient residing in a long-term care setting. What actions should the nurse implement to assess weight accurately? (Select all that apply.)

A) Weigh patient at the same time each day
B) Schedule weighing immediately after breakfast
C) Encourage patient to void before being weighed
D) Ensure same amount of clothing is worn by patient
E) Calibrate by setting scale at zero after each weight

Question 22

The home health nurse is preparing to educate a patient regarding electronic self-blood pressure measurement. What information should the nurse provide regarding this procedure? (Select all that apply.)

A) Expect precise values
B) Proper measurement techniques are necessary
C) Cuff fits over clothing
D) Stethoscope is not required
E) Recalibration is not necessary

Question 23

If a patient has an axillary temperature of 96.2°F, the nurse understands that the true temperature is ______.

Question 24

A patient is admitted to a medical surgical unit. What factors will determine how frequently vital signs will be assessed? (Select all that apply.)

A) Desire of the patient
B) Judgment of need by the nurse
C) Discretion of the family
D) Orders of the health care provider
E) Patient's condition

Question 25

When instructing a primary caregiver about keeping a daily log of blood pressure readings, what instructions should the nurse include? (Select all that apply.)

A) Take the reading at different times during the day.
B) Apply the cuff approximately 2 inches above the antecubital fossa.
C) If unable to get a reading the first time, immediately reinflate the cuff.
D) Assess pulse with the bell of the stethoscope.
E) Apply the cuff snugly.

Question 26

The nurse assesses the blood pressure as 192/86, noting that the patient has a pulse pressure of ________.

Question 27

A nurse assesses a patient's dorsalis pedis pulse. The pulse is easily felt but not palpable when moderate pressure is applied. How should the nurse document this finding?

A) Weak pulse
B) Normal pulse
C) Thready pulse
D) Bounding pulse

Question 28

The nurse assesses for the fifth vital sign, which is______________.

Question 29

When assessing factors that may influence the patient's pulse rate, what should the nurse take into consideration? (Select all that apply.)

A) Age
B) Sex
C) Emotion
D) Temperature
E) Religion

Question 30

A nurse assesses a patient's dorsalis pedis pulse. The pulse feels full and springlike even under moderate pressure. How should the nurse document this finding?

A) Weak pulse
B) Normal pulse
C) Thready pulse
D) Bounding pulse