Deck 5: Assessing Physiological Status: Vital Signs

Question 1

When assessing a patient's carotid pulse, which of the following would you most likely do?

A) Palpate one artery with a light, circular massaging motion during assessment.
B) Palpate both arteries simultaneously for accurate comparison.
C) Stand on the opposite side of the artery you are assessing.
D) Use two fingers to palpate just to the side of the larynx.

Answer 1

D

Question 2

Your new patient is a 51-year-old woman who had a myocardial infarction (heart attack) 5 weeks ago. She is now ready to begin outpatient cardiac rehabilitation. You assessed her resting heart rate at 78 beats per minute. Which of the following values would you use as a target heart rate for conditioning activities for this patient?

A) 92 beats per minute
B) 98 beats per minute
C) 108 beats per minute
D) 114 beat per minute

Answer 2

B

Question 3

Which of the following is true regarding blood pressure?

A) It is the range of pressure exerted by the blood in the ventricles.
B) The difference between systolic and diastolic pressures is pulse pressure.
C) Blood pressure is affected by blood volume and vessel compliance, not by vessel size.
D) Values are affected only by pathological conditions.

Answer 3

B

Question 4

List four factors that can affect blood pressure. ____________________

Question 5

List four factors that can affect a person's heart rate. ____________________

Question 6

The openness of arterial vessels is called ____________________.

Question 7

Which of the following is true regarding pain assessment in patient care?

A) Pain assessment is an objective measurement of the patient's experience.
B) Pain assessment is rarely useful in determining the underlying source of the pain.
C) Responses to pain are similar across all social and cultural groups.
D) Pain is always abnormal and can be a valuable indicator of a serious problem.
Completion
Complete each statement.

Question 8

Which of the following is true of the use of automated blood pressure monitors?

A) Cuff placement is more critical with the use of automated units than for auscultated measurement.
B) Finger units are the most accurate method of automated home blood pressure monitoring.
C) The arm should be placed in the same position as it is during auscultated measurement.
D) Automated monitors are generally less sensitive to changes in body movements.

Question 9

Explain how "counting from 1" is done when assessing pulse rate. ____________________

Question 10

You are working in a hospital and have just received a referral for a patient who had a surgical procedure yesterday. You want to assess his vital signs, including his pulse, before initiating any activity. Which of the following methods would be most appropriate for assessing this patient's pulse?

A) Count the pulse for 10 sec and multiply by 6.
B) Count the pulse for 15 sec and multiply by 4.
C) Count the pulse for 20 sec and multiply by 3.
D) Count the pulse for 60 sec.

Question 11

When the ventricles of the heart contract, the contraction pushes blood into the aorta. This is called ____________________. When the ventricles relax, returning blood refills the heart chambers. This is called ____________________.
Short Answer

Question 12

Your new patient has a diagnosis of chronic obstructive pulmonary disease. In addition to heart rate and blood pressure, which vital sign measurement would generally be the most meaningful in this patient?

A) Pedal pulse
B) Urinary output
C) Respiration
D) Temperature

Question 13

You are working in an outpatient rehabilitation setting. Your patient is a 39-year-old man who had knee surgery 4 weeks ago and is ready to begin aerobic conditioning activities. Which of the following represents this patient's estimated maximum heart rate?

A) 165 beats per minute
B) 181 beats per minute
C) 197 beats per minute
D) 216 beats per minute

Question 14

You are a therapist working in home health care. Your new patient is a 75-year-old woman who fell and broke her hip. She is home after a brief rehabilitation stay. Which of the following would typically be most important to include in your initial assessment?

A) Blood pressure
B) Lung sounds
C) Pedal pulses
D) Weight

Question 15

You are working with a man who had a bout of congestive heart failure. He is now quite deconditioned and is receiving 2 L of oxygen per minute through a nasal cannula. You are about to begin ambulation with this patient. Which of the following would be true in this clinical scenario?

A) Maximum oxygen saturation for this patient should be 95%.
B) Use of a fingertip pulse oximeter replaces the need to measure other physiological responses.
C) You will be concerned if the patient's oxygen saturation drops below 90%.
D) Monitoring oxygen saturation is not necessary while the patient is receiving supplemental oxygen.

Question 16

You are teaching your patient how to monitor his blood pressure at home. Which of the following is an important aspect of accurate home blood pressure monitoring?

A) Take at least two readings no more than 30 sec apart to get an accurate average.
B) Take the blood pressure at the same time every day.
C) Take the blood pressure only in the right arm.
D) Use a cuff with a width-to-length ratio 2:1.

Question 17

Which of the following blood pressure values indicates that the patient's exercises should be stopped immediately?

A) A diastolic reading >115 mm Hg
B) A 5 mm Hg drop from baseline in the systolic pressure
C) A failure of the diastolic pressure to increase with increasing workload
D) A systolic reading >180 mm Hg

Question 18

You are evaluating a new patient who had a stroke 6 days ago. Which of the following is the best method for assessing this patient's respiration?

A) Ask the patient to refrain from talking so that you can count her or his breathing rate.
B) Assess respiration during the patient's conversation so that he or she is unaware.
C) Check the nursing records to determine the patient's respiration rate.
D) Count the rise and fall of the chest for 30 sec while the patient is unaware.

Question 19

Which of the following actions is most likely to result in the inability to detect Korotkoff sounds accurately during blood pressure assessment?

A) The cuff is deflated fully prior to a second attempt.
B) The cuff is not inflated enough.
C) The cuff is over inflated.
D) The valve is opened too slowly.

Question 20

Which of the following assessment sites typically yields a temperature reading closest to a patient's core temperature?

A) Axilla
B) Ear
C) Mouth
D) Rectum