Deck 9: General Survey, vital Signs, and Pain

Question 1

You obtain a blood pressure of 105/62 in your patient's right arm but decide to take a second blood pressure reading to double-check the findings,because the blood pressure reading taken in the left arm an hour earlier was 143/91.To obtain an accurate reading,you should

A) immediately reinflate the cuff and listen carefully for the Korotkoff sounds.
B) wait 1-2 minutes before retaking the blood pressure.
C) remove the cuff and obtain an automatic blood pressure monitor.
D) retake the blood pressure in the patient's left leg.

Answer 1

wait 1-2 minutes before retaking the blood pressure.

Question 2

Which factor tends to increase the pulse rate?

A) increased blood pressure
B) increased vagal stimulation of the autonomic nervous system
C) pain
D) aging

Answer 2

pain

Question 3

Your patient's vital signs are pulse 74,respirations 20,temperature 37°C,and blood pressure 126/82.You determine that the patient's pulse pressure is which of the following?

A) 82
B) 74
C) 52
D) 44

Answer 3

44

Question 4

Core body temperature is the temperature of the blood circulating through the

A) heart and major arteries of the trunk.
B) abdominal organs.
C) hypothalamus.
D) mucous membranes.

Question 5

To obtain an accurate blood pressure reading,the nurse should

A) position the patient's arm slightly above the level of the heart.
B) apply the cuff with the inflated bladder over the brachial artery.
C) inflate the blood pressure cuff to approximately 40 mm Hg above the established baseline blood pressure.
D) look at the column of mercury with your eyes at the level of the meniscus of mercury.

Question 6

Your 6-year-old patient's respiratory rate is 36 breaths per minute,which you record as

A) within normal limits for his age.
B) tachypnea.
C) hyperpnea.
D) hyperventilation.

Question 7

Patients experiencing emotional or physical pain may exhibit similar signs,such as a pained facial expression.Which sign is most likely to indicate emotional pain rather than physical pain?

A) labored breathing and speech, wheezing, and shortness of breath
B) facial grimacing, crying, and moaning
C) diaphoresis, tachycardia, and physical protection of the painful area
D) excessive nail-biting, tearfulness, and avoidance of eye contact

Question 8

Which of the following is most likely to result in a lower body temperature?

A) ovulation
B) sleep
C) stress
D) exercise

Question 9

Listening carefully to the Korotkoff sounds as you deflate the blood pressure cuff,you detect the first sound at 146.It continues until 94,when the sounds are muffled,and eventually the sounds disappear at 40.Using the recommended method,you record this blood pressure as

A) 146/94.
B) 146/40.
C) 146/94/40.
D) 94/40/0.

Question 10

Your patient reported pulse volume of 2+/4+,which indicates that his pulse is

A) absent.
B) thready or weak.
C) normal.
D) bounding.

Question 11

Your patient has a pacemaker electrode and a central venous (CV)line in the right antecubital area and an arteriovenous (AV)shunt in his left lower arm.You determine that the most appropriate site to measure the blood pressure is which of the following?

A) left arm, above the AV shunt
B) right thigh
C) right arm if performed quickly to prevent interference with the electrode or CV line
D) right arm below the electrode and CV line

Question 12

Bradypnea,a respiratory rate of less than 12 breaths per minute in an adult at rest,commonly occurs with which of the following?

A) hypoxia
B) stress and anxiety
C) metabolic acidosis
D) decreased metabolic rate during normal sleep

Question 13

You observe that the right side of a patient's mouth droops and the affected side of her face appears flaccid.Which condition is most likely the cause of these findings?

A) depression
B) Bell's palsy
C) dementia
D) hypothyroidism

Question 14

To take the temperature of a 5-year-old child using the tympanic thermometer,you would pull the pinna up and back and gently insert the probe

A) toward the opposite eye.
B) upward toward the eye.
C) toward the opposite ear.
D) until it reaches the tympanic membrane.

Question 15

When do the Korotkoff sounds generate a clear,intense tapping?

A) phase I
B) phase II
C) phase III
D) phase IV

Question 16

A newly admitted 30-year-old patient has a resting pulse rate of 56.Which question,if answered affirmatively,is most likely to assist in determining the cause of the patient's bradycardia?

A) "Have you exercised in the past hour or so?"
B) "Are you taking digoxin?"
C) "Are you having pain?"
D) "Are you feeling stressed?"

Question 17

To assess a patient's apical pulse,the nurse would locate the apical pulse site and

A) gently palpate with the first three fingers for the pulsations.
B) press firmly with all five fingers, because the pulsations are difficult to locate at this site.
C) place the diaphragm of the stethoscope over the pulse site and listen for the heartbeat.
D) palpate the radial pulse while listening to the apical rate with the stethoscope.

Question 18

A general survey of a patient's physical presence would include which observation?

A) mood and manner
B) dress, grooming, and personal hygiene
C) facial expressions and speech
D) age, stature, and motor activity

Question 19

You are conducting a general assessment of a 6-years-old child.While the child is sitting on the examination table you assess his respiratory rate.You would begin by

A) first informing him of what you are doing.
B) counting the number of respirations in 15 seconds and multiplying by 2.
C) counting the respirations while measuring his pulse.
D) placing the stethoscope on his chest so he does not know you are counting respirations.

Question 20

An adult patient's blood pressure was obtained using an adult cuff at 2 PM and 3 PM,and the readings were 124/80 and 128/82.A pediatric blood pressure cuff was used to obtain the patient's blood pressure at 4 PM because the adult cuff was not available.The patient's blood pressure reading at 4 PM is most likely to be

A) within the same range.
B) slightly, but not significantly, lower.
C) erroneously high.
D) erroneously low.

Question 21

You are about to take the patient's temperature using a temporal artery thermometer.This procedure would require which of the following steps? Select all that apply.

A) Remove the protective cap from the probe head.
B) Position the probe head on the center of the forehead, midway between the eyebrow and hairline, and depress the scan button.
C) Rapidly, while applying pressure, move the thermometer across the forehead (in either direction) maintaining contact between the probe head and the patient's forehead until the hairline is reached.
D) Observe for a blinking light and/or beeping indicating that a measurement is being calculated.
E) Release the scan button and remove the thermometer from the patient's forehead.Read the temperature on the display screen.
F) Discard the protective cap and the probe.

Question 22

A patient's blood pressure is 168/102 in the left arm and 175/104 in the right arm.According to The Joint National Committee's seventh report,in which BP classification category would this patient be?

A) normal
B) prehypertension
C) stage 1 hypertension
D) stage 2 hypertension

Question 23

Which of the following conditions may cause bradycardia? Select all that apply.

A) Diarrhea
B) Eye surgery
C) Hyperthyroidism
D) Prolonged vomiting
E) Myocardial infarction
F) Increased intracranial pressure

Question 24

A weak,thready pulse can be caused by ____________________ shock.

Question 25

The nurse knows that when hospitalized adolescents underrate their pain and hide it,they are most likely denying pain for which of the following reasons?

A) They are concerned that taking pain medication will lead to addiction.
B) They hope to get discharged from the hospital quicker.
C) They are afraid that an injection to relieve pain will hurt more than the pain they have.
D) They want to show their strength and maturity by coping with significant pain.

Question 26

An apical pulse rate greater than the radial pulse rate is called ____________________.

Question 27

Which example indicates confirmed hypertension?

A) patient whose blood pressure is 150/96 after 20 minutes of aerobic exercise
B) patient whose blood pressure is 162/104 before dental surgery
C) patient whose blood pressure is 165/98 and 146/92 taken at the beginning and end of a routine physical assessment
D) patient whose blood pressure is 152/96 and 154/98 taken on two consecutive visits with his family physician after an initial screening

Question 28

A variation between a patient's standing blood pressure reading of 104/64 and a supine reading of 138/88 is most likely because the patient has ______________________________.

Question 29

Increased pulse pressure can be caused by which of the following? Select all that apply.

A) Cold
B) Heat
C) Hypothyroidism
D) Hyperthyroidism
E) Arteriovenous fistula
F) Decreased stroke volume

Question 30

Which pain assessment tool is verbally administered and can assess sensory,affective,and evaluative aspects of pain?

A) McGill Pain Questionnaire
B) Oucher Pain Assessment Tool
C) Initial Pain Assessment Inventory
D) Wong-Baker FACES Pain Rating Scale

Question 31

While examining a patient admitted for acute appendicitis,the patient complains of pain in the abdominal region.You recognize that the patient is experiencing which type of pain?

A) somatic pain
B) cutaneous pain
C) chronic pain
D) visceral pain

Question 32

Bradypnea can be caused by which of the following? Select all that apply.

A) Alcohol which depresses the respiratory center of the brain
B) A higher metabolic rate occurring during normal sleep
C) Medications which depress the respiratory center of the brain
D) A lower metabolic rate occurring during normal sleep
E) A lower metabolic rate occurring during strenuous exercise
F) Head injury resulting in increased intracranial pressure in the respiratory center

Question 33

Poor oral hygiene,allergic rhinitis,or infections such as tonsillitis,sinusitis,or pneumonia can be indicated by bad ____________________.

Question 34

You enter your patient's room and notice an ammonia odor.Which of the following conditions can cause an ammonia odor?

A) Renal failure
B) Intestinal obstruction
C) Severe vaginitis
D) Diabetic ketoacidosis

Question 35

Which pain assessment tool is a visual tool that can be completed by the nurse or the patient?

A) Brief Pain Inventory
B) Initial Pain Assessment Inventory
C) CRIES
D) The McGill Pain Questionnaire

Question 36

A patient complains of pain.When caring for this patient,the most important thing the nurse must recall is that

A) administering medications for pain will always lead to addiction.
B) the patient experiencing the pain is the authority on the pain that is being felt.
C) the patient's behavior is always consistent with the amount of pain experienced.
D) the extent of a patient's pain is related specifically to the type of illness the patient has.

Question 37

Your examination of a newly admitted patient reveals that the patient's vital signs are pulse 68,respirations 22,temperature 37.2C,and blood pressure 130/88.You hypothesize that the pulse pressure is which of the following?

A) 42
B) 47
C) 59
D) 62

Question 38

You are conducting an examination of a patient admitted with pancreatitis.The patient complains of pain in the left shoulder.You hypothesize that the patient is experiencing which type of pain?

A) somatic pain
B) referred pain
C) visceral pain
D) cutaneous pain

Question 39

Halitosis can be caused by which of the following? Select all that apply.

A) Tonsilitis
B) Vaginal infection
C) Pneumonia
D) Allergic rhinitis
E) Tooth decay
F) Poor oral hygiene