Question 1

A nurse takes a patient's vital signs. Which of the following is considered a vital sign?&#10;A) mental status&#10;B) visual acuity&#10;C) blood pressure&#10;D) urinary output

Accepted Answer

Vital signs are measurements related to basic body functions that can provide important information about a patient's overall health status. The four main vital signs are body temperature, pulse rate, respiratory rate, and blood pressure. Of the options given, blood pressure is the only one that falls into the category of vital signs. Mental status and visual acuity are important assessments to make, but they are not typically considered vital signs. Urinary output may be monitored in certain situations, but it is not a vital sign.

Question 2

In which of the following situations is it protocol for the nurse to take a patient's vital signs? Select all that apply.&#10;A) upon admitting a patient to a hospital&#10;B) at a healthcare screening&#10;C) when medications are given for a cardiac arrhythmia&#10;D) following a diagnostic procedure&#10;E) prior to an invasive procedure&#10;F) when daily medications are dispensed

Accepted Answer

A, B, C, D, E

Question 3

Which of the following pathologic conditions would result in release of ADH by the posterior pituitary?&#10;A) hemorrhage&#10;B) allergies&#10;C) obesity&#10;D) asthma

Accepted Answer

Hemorrhage causes a decrease in blood volume and blood pressure, which stimulates the release of ADH from the posterior pituitary to decrease urinary output and retain water in the body. Allergies, obesity, and asthma do not directly affect ADH release.

Question 4

While assessing vital signs of a patient with a head injury and increased intracranial pressure (IICP), a nurse notes that the patient's respiratory rate is 8 breaths/min. How will the nurse interpret this finding?

A) bradypnea is uncommon in patient with IICP
B) IICP most commonly results in tachypnea
C) bradypnea is a response to IICP
D) this is a normal respiratory rate

Accepted Answer

Bradypnea is a response to IICP, as it is the body's attempt to decrease the amount of carbon dioxide in the blood and therefore decrease cerebral blood flow. Tachypnea is not a common finding in patients with IICP. A respiratory rate of 8 breaths/min is not normal, as a normal respiratory rate for an adult is between 12-20 breaths/min.

Question 5

A patient has been diagnosed with peripheral vascular disease of the lower extremities. What site would the nurse use to assess circulation of the legs?&#10;A) radial artery&#10;B) dorsalis pedis artery&#10;C) temporal artery&#10;D) carotid artery

Accepted Answer

The dorsalis pedis artery is located on the top of the foot and is often used to assess circulation in the legs, particularly in patients with peripheral vascular disease. The radial artery is located in the wrist and is used to assess circulation in the arms. The temporal artery is located on the side of the head and is used to assess blood flow to the brain. The carotid artery is located in the neck and is used to assess blood flow to the head and neck.

Question 6

A student nurse assesses a blood pressure on an adult and finds it to be 140/86. What term is used for the top number (140)?&#10;A) systolic pressure&#10;B) diastolic pressure&#10;C) pulse pressure&#10;D) hypotension

Accepted Answer

The top number in a blood pressure reading (140 in this case) is known as the systolic pressure.

Question 7

What equipment is needed to take an apical pulse?&#10;A) sphygmomanometer&#10;B) electronic thermometer&#10;C) stethoscope&#10;D) no specific equipment

Accepted Answer

A stethoscope is needed to take an apical pulse as it involves listening to the heartbeat through the chest wall.

Deck 16: Vital Signs