Question 1

When asked why pain is considered the sixth vital sign, a nurse explains to a patient that pain

Accepted Answer

Pain is considered the sixth vital sign because it provides a baseline measurement for slight changes. This can be helpful in identifying the effectiveness of pain management interventions.

Question 2

A nurse explains to a patient that blood pressure measures

Accepted Answer

Blood pressure measures the amount of force being placed on arteries by blood.

Question 3

During auscultation, the nurse hears fine rales in the patient's lower lobes bilaterally. Fine rales are described as

Accepted Answer

Fine rales are high-pitched, short, crackling sounds heard during the end of inspiration and are often compared to the sound of hair being rubbed between fingers, indicating the presence of fluid in the alveoli.

Question 4

A nurse explains to a patient's family that his respirations are faster and deeper than normal because

Accepted Answer

Faster and deeper respirations, also known as hyperventilation, typically occur in response to low oxygen levels in the blood (hypoxemia).

Question 5

A nurse expects that the blood pressure will increase in the patient who

Accepted Answer

An increased blood volume, such as during pregnancy, can lead to a higher blood pressure. The other options all suggest factors that would lower blood pressure, not increase it.

Question 6

Upon entering a patient's room, a nurse decides to check the patient's vital signs rather than delegate the task. Which of the following reasons would best justify the nurse's decision not to delegate the task?

Accepted Answer

The nurse's nagging concern suggests that something may be wrong with the patient, and it is therefore appropriate for the nurse to personally assess the patient's vital signs.

Question 7

A nurse closely monitors a patient with a head injury. Upon assessment of vital signs, the nurse notes changes indicative of increased intracranial pressure caused by brain swelling. Which changes depict increased intracranial pressure?

Accepted Answer

Increased intracranial pressure (ICP) can lead to Cushing's triad, which is characterized by increased systolic blood pressure, decreased pulse rate, and irregular respirations. This response is the body's attempt to maintain cerebral perfusion in the face of increased ICP.

Question 8

While looking over the chart of an elderly patient, a nurse noted several findings that are to be expected as a result of long-standing hypertension. One of those findings would be

Accepted Answer

Long-standing hypertension can lead to kidney damage and eventually kidney failure, which can be reflected in blood work. A chest radiograph would not be directly related to hypertension, nor would a brain scan ruling out Alzheimer's disease. Blood work ruling out a heart attack is not a finding related to hypertension specifically.

Question 9

A febrile patient's mother asks the nurse why her daughter's breathing rate is increased. The nurse replies:

Accepted Answer

Fever increases the body's metabolic rate, leading to increased oxygen demand and carbon dioxide production, which causes an increase in both heart and respiratory rates.

Question 10

A nurse is unable to palpate a patient's dorsalis pedis pulse. The nurse will next attempt to palpate the

Accepted Answer

If the nurse is unable to palpate the dorsalis pedis pulse, the next best location to attempt to palpate a pulse would be the posterior tibialis pulse on the inner ankle. The brachial pulse is located in the upper arm, the carotid pulse is located in the neck, and the femoral pulse is located in the groin area, none of which are directly related to the dorsalis pedis pulse location.

Question 11

A patient has told a nurse that she will not use artificial means to prevent pregnancy. The nurse describes monitoring temperature as a natural method of birth control. The nurse explains to the patient that ovulation can be identified by an increase in body temperature caused by

Accepted Answer

An increase in progesterone causes a rise in body temperature during ovulation. This can be used as a natural method of birth control by monitoring the temperature daily and abstaining from intercourse during the time of ovulation.

Question 12

A nurse, unable to palpate the left pedal pulse on a patient with diabetes, should next

Accepted Answer

Using the Doppler to listen for the left pedal pulse is the appropriate next step as it provides a more accurate assessment of the presence or absence of the pedal pulse. It is important to determine if the patient has peripheral artery disease, and if the absence of pulse is a chronic or acute problem. Charting the inability to palpate the pulse and notifying the physician may also be necessary, but using the Doppler is the priority action. Calling the nurse supervisor to report the pedal pulse was zero is not appropriate as the nurse should not state that the pulse was zero without properly assessing it first.

Question 13

Upon checking on a patient, a nurse discovers the patient appeared to experience some shortness of breath while walking back from the restroom. The nurse determines that the patient may be experiencing

Accepted Answer

Exertional dyspnea is shortness of breath that occurs during physical activity or exertion. In this case, the patient experienced shortness of breath while walking, indicating that the dyspnea is likely exertional.

Question 14

A nurse understands that a patient with a history of congestive heart failure has a low cardiac output resulting from

Accepted Answer

Congestive heart failure is a condition where the heart muscle becomes weakened and damaged, leading to a reduced ability to pump blood efficiently. This results in a low cardiac output, as the heart is not able to circulate enough blood to meet the body's demands.

Question 15

After taking a patient's vital signs, a nurse removes the blankets used to cover the patient because the patient's temperature was

Accepted Answer

The nurse removes the blankets to help lower the patient's temperature because 102.6°F oral indicates a fever, which is higher than the normal body temperature range.

Question 16

While listening to a patient's apical pulse, a nurse identifies that it is difficult to hear both heart sounds. This would be charted as:

Accepted Answer

When a nurse identifies that it is difficult to hear both heart sounds while listening to a patient's apical pulse, it would be charted as "heart tones are muffled." This is because muffled heart sounds indicate that the sound waves are not being transmitted well through the chest wall and may indicate a problem with the heart's functioning. Distinct or strong heart tones would indicate the opposite, while absent heart tones would indicate that no sound is heard at all.

Question 17

A nurse explains to a patient with hypertension that diastolic pressure is a measurement of

Accepted Answer

Diastolic pressure is the pressure exerted by the blood on the arterial walls during the ventricles' relaxation.

Question 18

A nurse explains to a patient that it is important to slowly change positions to diminish or eliminate the symptoms of

Accepted Answer

Postural hypotension occurs when there is a sudden drop in blood pressure upon standing up from a sitting or lying down position. To prevent or alleviate symptoms, it is important to slowly change positions to allow time for blood pressure to adjust accordingly.

Question 19

A patient admitted with hypertension asks the nurse what causes blood pressure to elevate. The nurse replies:

Accepted Answer

A long history of smoking can lead to damage of the blood vessels, causing them to become less elastic and increase resistance to blood flow, leading to elevated blood pressure.

B is incorrect as race does not determine blood pressure. 
C is incorrect as getting enough sleep can actually help regulate blood pressure. 
D is incorrect as there are known factors that can contribute to elevated blood pressure such as smoking, obesity, and stress.

Question 20

When asked by a patient's family how core temperature differs from tympanic temperature, a nurse says:

Accepted Answer

Core temperature refers to the temperature inside the body, whereas tympanic temperature is obtained by placing a thermometer in the ear canal, which may not be as reflective of the internal environment. Therefore, taking the core temperature is more reflective of the environment the internal organs are being exposed to. Choices A, C, and D do not accurately describe the difference between core and tympanic temperatures.

Quiz 17: Vital Signs