Deck 4: Vital Signs and Pain Assessment

Question 1

Which of the following occurs with malignant hypertension?

A) Blurred vision
B) Sleep disturbance
C) Tachycardia
D) Dyspnea
E) Encephalopathy

Answer 1

Blurred vision
Dyspnea
Encephalopathy

Question 2

The perception of pain:

A) is the same across cultures.
B) can be easily assessed in neonates.
C) is predictable with the same circumstances.
D) is affected by emotions and quality of sleep.

Answer 2

is affected by emotions and quality of sleep.

Question 3

The fifth vital sign is:

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

Answer 3

pain.

Question 4

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

Question 5

Body language that leads you to suspect that a person is in pain is:

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

Question 6

Underestimation of blood pressure will occur if the cuff's width covers:

A) less than half of the upper arm.
B) less than 5 inches of the lower arm.
C) more than two thirds of the upper arm.
D) more than 4 inches of the lower arm.

Question 7

Hypertension in the adult is generally defined as pressure in excess of:

A) 120 mm Hg plus the patient's age.
B) 140 mm Hg.
C) 160 mm Hg.
D) 200 mm Hg.

Question 8

The Joint Commission (TJC) requires that:

A) pain be assessed on all discharges.
B) repeated assessment of pain be limited to those patients who complain of pain.
C) repeated intensity documentation be made of the course of pain relief for all patients.
D) pain be assessed on surgical patients.

Question 9

Ms. Green is an 85-year-old female patient with dementia who presents to the emergency department with her daughter because of a change in function. Which pain assessment scale would be the best choice?

A) Oucher Scale
B) Checklist for Nonverbal Pain Indicators
C) Wong/Baker Rating Scale
D) CRIES Scale

Question 10

In a syndrome in which regional pain extends beyond this specific peripheral nerve injury, you would notice which of the following:

A) Allodynia
B) Sleep disturbance
C) Blood flow changes
D) Numbness
E) Edema

Question 11

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.
D) preload.

Question 12

During respiration, the internal intercostals:

A) increase the force of muscular contraction.
B) decrease the lateral diameter during expiration.
C) decrease the intrathoracic space.
D) increase elastic recoil during expiration.

Question 13

If a sufficiently large cuff is unavailable to fit an obese arm, 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.

Question 14

Postural hypotension is defined as a ___________________ when the patient stands compared with sitting or supine readings.

A) systolic pressure drop of more than 15 mm Hg with a pulse rate increase
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

Question 15

The most frequent cause of serious hypertension in children is:

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

Question 16

A blood pressure cuff bladder should be long enough to:

A) cover 20% to 25% of the arm circumference.
B) cover 45% to 50% of the arm circumference.
C) cover 75% to 80% of the arm circumference.
D) completely encircle the arm.

Question 17

The pyrexia response is triggered by the production and release of:

A) prostaglandins.
B) endogenous pyrogens.
C) hypothalamic enzymes.
D) thyroid hormones.

Question 18

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.

Question 19

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

Question 20

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

Question 21

You are completing an examination on a 4-year-old child. Pain scales that are reliable and valid for children are the _____ Scales.

Question 22

Pain is often referred to as the fifth vital sign because ____________________.