Question 1

The patient is restless with a temperature of 102.2° F (39° C).One of the first things the nurse should do is

Accepted Answer

During a fever,cellular metabolism increases and oxygen consumption rises.Myocardial hypoxia produces angina.Cerebral hypoxia produces confusion.Interventions during a fever include oxygen therapy.Dehydration is a serious problem through increased respiration and diaphoresis.The patient is at risk for fluid volume deficit.Fluids should not be restricted.Increasing activity would increase the metabolic rate further,which would not be advisable.

Question 2

Of the following mechanisms of heat loss by the body,identify the mechanism that transfers heat away by using air movement?

Accepted Answer

Convection is the transfer of heat away from the body by air movement.Conduction is the transfer of heat from one object to another with direct contact.Radiation is the transfer of heat from the surface of one object to the surface of another without direct contact between the two.Evaporation is the transfer of heat energy when a liquid is changed to a gas.

Question 3

While the nurse is assessing the patient's respirations,it is important for the patient to

Accepted Answer

Do not let a patient know that respirations are being assessed.A patient who is aware of the assessment can alter the rate and depth of breathing.Respirations are the easiest of all vital signs to assess,but they are often the most haphazardly measured.Do not estimate respirations.Accurate measurement requires observation and palpation of chest wall movement.

Question 4

When focusing on temperature regulation of newborns and infants,the nurse understands that

Accepted Answer

A newborn loses up to 30% of body heat through the head and therefore needs to wear a cap to prevent heat loss.Temperature control mechanisms in newborns are immature and respond drastically to changes in the environment.The normal temperature range gradually drops as individuals approach older adulthood.

Question 5

The patient requires temperatures to be taken every two hours.Which of the following cannot be delegated to nursing assistive personnel?

Accepted Answer

The nurse is responsible for assessing changes in body temperature.The nurse instructs nursing assistive personnel to select the appropriate route and device to measure temperature,to obtain temperature measurement at ordered frequency,and to be aware of the usual values for the patient.

Question 6

The thickness or viscosity of the blood affects the ease with which blood flows through small vessels.The nurse examines what value,which might help determine the amount of blood viscosity?

Accepted Answer

The hematocrit,or the percentage of red blood cells in the blood,determines blood viscosity.Blood pressure also depends on the cardiac output or volume pumped by the heart,but cardiac output does not affect viscosity.Arterial size helps to modify blood pressure.The smaller lumen of a vessel increases vascular resistance but does not affect viscosity.Blood volume also affects blood pressure,but it does not directly affect viscosity.

Question 7

The nurse is caring for a patient who has an elevated temperature.The nurse understands that

Accepted Answer

Fever and hyperthermia are not the same things.An elevated body temperature related to the body's inability to promote heat loss or reduce heat production is hyperthermia.Fever is an upward shift in the set point.Hyperthermia is not a shift in the set point.

Question 8

The patient has a temperature of 105.2° F.The nurse is attempting to lower his temperature by providing tepid sponge baths and placing cool compresses in strategic body locations.The nurse is attempting to lower the patient's temperature through the use of

Accepted Answer

Applying an ice pack or bathing a patient with a cool cloth increases conductive heat loss.Radiation is the transfer of heat from the surface of one object to the surface of another without direct contact between the two.Evaporation is the transfer of heat energy when a liquid is changed to a gas.Convection is the transfer of heat away from the body by air movement.

Question 9

The patient requires routine temperature assessment but is confused and easily agitated and has a history of seizures.The nurse's best option would be to take his temperature

Accepted Answer

The tympanic route is easily accessible,requires minimal patient repositioning,and often can be used without disturbing the patient.It also has a very rapid measurement time.Oral temperatures require patient cooperation and are not recommended for patients with a history of epilepsy.Rectal temperatures require positioning and may increase patient agitation.Axillary temperatures need long measurement times and continuous positioning by the nurse.The patient's agitation state may not allow for long periods of attention.

Question 10

The nurse is working the night shift on a surgical unit and is making 4 AM rounds.She notices that the patient's temperature is 96.8° F (36° C),whereas at 4 PM the preceding day,it was 98.6° F (37° C).What should the nurse do?

Accepted Answer

Body temperature normally changes 0.5° C to 1° C (0.9° F to 1.8° F)during a 24-hour period and is usually lowest between 1:00 and 4:00 AM,making this variation normal for the time of day.Unless the patient is complaining of being cold,there is no physiological need for providing an extra blanket or medication to lower the body temperature further.There is also no need to call a physician to report a normal temperature variation.

Question 11

The nurse needs to obtain a radial pulse from a patient.To obtain the correct measure,what must the nurse do?

Accepted Answer

Place the tips of the first two or middle three fingers of the hand over the groove along the radial or thumb side of the patient's inner wrist.Fingertips are the most sensitive parts of the hand to palpate arterial pulsation.The thumb has a pulsation that interferes with accuracy.The pulse is more accurately assessed with moderate pressure.Too much pressure occludes the pulse and impairs blood flow.

Question 12

The patient is being admitted to the emergency department following a motor vehicle accident.His jaw is broken,and he has several broken teeth.He is ashen,and his skin is cool and diaphoretic.To obtain an accurate temperature,the nurse uses which of the following routes?

Accepted Answer

The rectal route is argued to be more reliable when oral temperature cannot be obtained.Oral temperatures are not used for patients who have had oral surgery,trauma,history of epilepsy,or shaking chills.Axillary temperature is affected by exposure to the environment,including time to place the thermometer.It also requires a long measurement time.Temporal artery temperature is affected by skin moisture such as diaphoresis or sweating.

Question 13

The patient's blood pressure is 140/60.The nurse realizes that this equates to a pulse pressure of

Accepted Answer

The difference between the systolic pressure and the diastolic pressure is the pulse pressure.For a blood pressure of 140/60,the pulse pressure is 80 (140 - 60 = 80).140 is the systolic pressure.60 is the diastolic pressure.200 is the systolic (140)added to the diastolic (60),but this has no clinical significance.

Question 14

The posterior hypothalamus helps control temperature by

Accepted Answer

If the posterior hypothalamus senses that the body's temperature is lower than the set point,the body initiates heat conservation mechanisms.Vasoconstriction of blood vessels reduces blood flow to the skin and extremities.The anterior hypothalamus controls heat loss by inducing sweating,vasodilation of blood vessels,and inhibition of heat production.

Question 15

The patient is found to be unresponsive and not breathing.To determine the presence of central blood circulation and circulation of blood to the brain,the nurse checks the patient's _____ pulse.

Accepted Answer

The heart continues to deliver blood through the carotid artery to the brain as long as possible.The carotid pulse is easily accessible during physiological shock or cardiac arrest.The radial pulse is used to assess peripheral circulation or to assess the status of circulation to the hand.The brachial site is used to assess the status of circulation to lower arm.The posterior tibial pulse is used to assess the status of circulation to the foot.

Question 16

The nurse is caring for a patient who has a temperature reading of 100.4° F (38° C).His last two temperature readings were 98.6° F (37° C)and 96.8° F (36° C).The nurse should

Accepted Answer

Waiting an hour and rechecking the patient's temperature would be the most appropriate action in this case.A fever usually is not harmful if it stays below 102.2° F (39° C),and a single temperature reading does not always indicate a fever.In addition to physical signs and symptoms of infection,a fever determination is based on several temperature readings at different times of the day compared with the usual value for that person at that time.Mild temperature elevations enhance the body's immune system by stimulating white blood cell production.Usually,staff nurses do not order blood cultures,and nurses should base actions on knowledge,not on assumptions.

Question 17

The nurse is caring for an infant and is obtaining the patient's vital signs.The best site for the nurse to obtain the infant's pulse would be the _____ artery.

Accepted Answer

The brachial or apical pulse is the best site for assessing an infant's or a young child's pulse because other peripheral pulses such as the radial,femoral,and popliteal arteries are deep and are difficult to palpate accurately.

Question 18

When heat loss mechanisms of the body are unable to keep pace with excess heat production,the result is known as

Accepted Answer

Pyrexia,or fever,occurs because heat loss mechanisms are unable to keep pace with excess heat production,resulting in an abnormal rise in body temperature.The set point is the temperature point determined by the hypothalamus.When pyrogens trigger immune system responses,the hypothalamus reacts to raise the set point,and the body produces and conserves heat.During the plateau phase,chills subside and the person feels warm and dry as heat production and loss equilibrate at the new level.When the fever "breaks," the patient becomes afebrile.

Question 19

The patient is being admitted to the emergency department with complaints of shortness of breath.The patient has had chronic lung disease for many years but still smokes.The nurse should

Accepted Answer

Because low levels of arterial O₂ provide the stimulus that allows the patient to breathe,administration of high oxygen levels will be fatal for patients with chronic lung disease.Oxygen must be used cautiously in these types of patients.Patients with chronic lung disease have ongoing hypercarbia (elevated CO₂ levels)and do not need to have CO₂ administered or "rebreathed."

Question 20

Which statement is true of the ovulation phase?

Accepted Answer

Progesterone levels rise and fall cyclically during the menstrual cycle.When progesterone levels are low,the body temperature is a few tenths of a degree below the baseline.The lower temperature persists until ovulation occurs.During ovulation,greater amounts of progesterone enter the circulatory system and raise the body temperature to previous baseline levels or higher.These temperature variations help to predict a woman's most fertile time to achieve pregnancy.Women who undergo menopause (cessation of menstruation)often experience periods of intense body heat and sweating lasting from 30 seconds to 5 minutes (hot flashes).

Quiz 29: Vital Signs

The patient is restless with a temperature of 102.2° F (39° C) .One of the first things the nurse should do is