Deck 17: Vital Signs

Question 1

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

A) Indicates the prescribed pain medication is not sufficient.
B) Is thought to be at the root of all changes in vital signs.
C) Increases the blood pressure to dangerous levels.
D) Is a baseline that allows measurement of slight changes.

Answer 1

Is a baseline that allows measurement of slight changes.

Question 2

A nurse explains to a patient that blood pressure measures

A) The amount of blood volume within the blood vessels.
B) The amount of resistance within the veins during heart contractions.
C) The amount of force being placed on arteries by blood.
D) The amount of pressure exerted by the veins and arteries on the heart.

Answer 2

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

A) Noisy, snoring sounds during respirations.
B) Musical or whistling sounds with respirations.
C) A sonorous wheeze upon inspiration.
D) Sounding like hair being rubbed between the thumb and index fingers.

Answer 3

Sounding like hair being rubbed between the thumb and index fingers.

Question 4

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

A) His blood oxygen level indicates hypoxemia.
B) He is using his intercostal muscles to breathe.
C) He has developed an inflammation of the phrenic nerve.
D) He is expelling too much carbon dioxide.

Question 5

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

A) Avoids caffeine, nicotine, and a sedentary lifestyle.
B) Is in top physical condition.
C) Has an increased blood volume, as happens during pregnancy.
D) Has a history of hypotension.

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?

A) The patient has just ambulated to the bathroom.
B) The nurse has a nagging concern that something is not right.
C) The patient is being discharged from the hospital.
D) The patient has a long history of hypertension.

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?

A) Decreased temperature and decreased blood pressure
B) Increased blood pressure, increased temperature, increased respirations, and increased pulse rate
C) Decreased blood pressure, increased pulse rate, and increased respiratory rate
D) Increased blood pressure, decreased respiratory rate, and decreased pulse rate

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

A) A chest radiograph indicating the possibility of pneumonia.
B) Blood work suggestive of kidney failure.
C) A brain scan ruling out a diagnosis of Alzheimer disease.
D) Blood work ruling out a myocardial infarction, or heart attack.

Question 9

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

A) "It is normal for the fever to increase her metabolic rate. Because the heart and lungs work together, you see her breathing speed up along with her heart rate."
B) "It is quite normal for this to happen, so you can expect her respiratory rate to increase by 8 to 10 respirations per minute for each 1°F elevation in temperature."
C) "Breathing speeds up when the temperature is elevated to blow off some of the body heat."
D) "It is rare that respirations are affected by fever. We should be very concerned about this."

Question 10

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

A) Brachial pulse.
B) Carotid pulse.
C) Femoral pulse.
D) Posterior tibialis.

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

A) The release of estrogen.
B) Inflammation in the ovary.
C) An increase in progesterone.
D) Stimulation from ephedrine.

Question 12

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

A) Chart: "Unable to palpate left pedal pulse."
B) Notify the physician that the pulse could not be palpated.
C) Use the Doppler to listen for the left pedal pulse.
D) Call the nurse supervisor to report the pedal pulse was zero.

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

A) Episodes of orthopnea.
B) Cheyne-Stokes respirations.
C) Eupnea.
D) Exertional dyspnea.

Question 14

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

A) An expected increase in stroke volume.
B) A long history of pain and fatigue.
C) The low blood volume that accompanies congestive heart failure.
D) Weakened and damaged heart muscle.

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

A) 100°F axillary.
B) 97.8°F rectal.
C) 99.1°F tympanic.
D) 102.6°F oral.

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:

A) "Heart tones are distinct."
B) "Heart tones are strong."
C) "Heart tones are absent."
D) "Heart tones are muffled."

Question 17

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

A) The amount of force blood places on the arterial walls while the ventricles relax.
B) The amount of force blood places on the arterial walls while the ventricles contract.
C) The amount of force blood places on the arterial walls while both the atria and the ventricles relax.
D) The amount of force blood places on the arterial walls while both the atria and the ventricles contract.

Question 18

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

A) Essential hypertension.
B) Pulse pressure.
C) Postural hypotension.
D) Pre-hypertension.

Question 19

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

A) "A long history of smoking can raise the blood pressure over time."
B) "Blood pressure often is elevated in Asian races."
C) "Blood pressure can increase by getting in excess of 6 to 8 hours of sleep every night."
D) "We're not sure what factors are involved in raising blood pressure."

Question 20

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

A) "A tympanic temperature is obtained using sterile technique and is more time consuming."
B) "Taking the core temperature is more reflective of the environment the internal organs are being exposed to."
C) "Obtaining a core temperature far outweighs the benefits of a tympanic temperature because it is less invasive."
D) "Taking a tympanic temperature is uncomfortable and more invasive."

Question 21

A nurse is assessing a sedated patient whose respiratory rate has fallen below 12 respirations per minute. The nurse identifies this condition as

A) Eupnea.
B) Bradypnea.
C) Tachypnea.
D) Apnea.

Question 22

An instructor is discussing various factors that can affect a patient's blood pressure. The instructor identifies that additional teaching is needed when a student says:

A) "Herbs, over-the-counter medications, and illicit drugs can all affect a patient's blood pressure."
B) "Blood pressure is higher in some overweight and obese individuals."
C) "Dehydration tends to raise a patient's blood pressure."
D) "The average systolic pressure in newborns is around 40 mm Hg."

Question 23

Before taking a patient's blood pressure, a nurse should do which of the following?

A) Review the graphic sheet to identify how high to inflate the cuff.
B) Ask the patient if there is a reason to not take the blood pressure on either arm.
C) Change the ear pieces of the stethoscope.
D) Assess the patient's peripheral pulses.
E) Lower the bed to its lowest position.

Question 24

A nurse is caring for a patient with kidney disease whose respirations have increased in rate and depth, with long, strong, blowing or grunting exhalations. The nurse identifies this condition as

A) Biot respirations.
B) Kussmaul's respirations.
C) Cheyne-Stokes respirations.
D) Korotkoff sounds.

Question 25

A nurse explains to a patient's family that there are six vital signs monitored on all patients: blood pressure, temperature, pulse, respirations, pain, and ____________________.

Question 26

A nurse knows that while performing CPR, blood flow to the patient's brain can be impaired and possibly cause a stroke if he or she

A) Accesses a patient using any peripheral pulse site.
B) Palpates the radial artery.
C) Palpates both carotid pulses at the same time.
D) Palpates the femoral artery.

Question 27

Upon taking a patient's vital signs, a nurse finds that the patient's temperature is 105.4°F (40.5°C). Using appropriate medical terminology, the nurse charts that the patient has ____________________.

Question 28

While assessing a patient's pulse, a nurse identifies that the pulse obliterates. This means the pulse

A) Is full and has a bounding quality.
B) Is weak, faint, and not perfusing.
C) Disappears upon palpation.
D) Indicates contractions are perfusing.

Question 29

It is considered inappropriate to delegate vital sign assessment to certified nursing assistants (CNAs) or unlicensed assistive personnel (UAPs) in which of the following situations?

A) A patient is being admitted to the facility.
B) A patient is in an unstable postoperative condition.
C) A patient is obese.
D) A patient is being administered intravenous (IV) medications that may affect the vital signs.
E) A patient has pale, cold, and clammy skin.

Question 30

A primary care physician has told a patient that she has a pulse deficit. She asks her nurse to explain what that means. The nurse replies:

A) "It is when your radial pulse is faster than your apical pulse, and they should always be equal."
B) "The irregularity of your heart beat is compromising your blood flow, resulting in your radial pulse being slower than your heart rate."
C) "A pulse deficit exists when the heart sounds become distant and, in some cases, such as yours, muffled."
D) "Pulse deficit simply means that your heart muscle has been damaged and can no longer pump as effectively."

Question 31

A nurse is educating young parents regarding the proper medication to use for fever reduction in children. It is important that the nurse makes sure that the parents understand that

A) Aspirin should never be given to children with a virus.
B) Parents should never give their children ibuprofen.
C) Acetaminophen should never be used to treat a child's fever.
D) Advil should never be used to treat a fever in patients younger than 15 years.

Question 32

A nurse understands there are many factors that can affect a patient's temperature. The nurse explains to a patient that which of the following situations can falsely lower the body temperature?

A) Drinking something cold
B) Exercising
C) An outdoor temperature of 99°F
D) A cold climate
E) Physical inactivity

Question 33

A nurse takes a tympanic temperature in a 2-year-old patient by pulling the pinna

A) Upward and back.
B) Upward and forward.
C) Downward and forward.
D) Downward and back.

Question 34

The pulse oximeter indicates a patient's blood oxygen level is 89%. A nurse knows that it is important to

A) Verify the oximeter is placed on a site that has adequate capillary refill.
B) Call the laboratory and order arterial blood gases to get a more accurate oxygen level.
C) Encourage the patient to get out of bed and ambulate more.
D) Let the patient rest quietly to reduce the need for oxygen.

Question 35

A nurse determines that vital signs will need to be repeated within 4 hours in which of the following examples of recorded patient vital signs?

A) Blood pressure (BP) 164/90, temperature (T) 98.4°F, pulse rate (P) 89 bounding and regular, respiration rate (R) 26
B) BP 116/72, T 100.6°F, P 88 strong and regular, R 32
C) BP 110/74, T 97.8°F, P 74 strong and regular, R 19
D) BP 128/68, T 98.6°F, P 80 strong and regular, R 20
E) BP 112/86, T 97.8°F, P 48 weak and irregular, R 24

Question 36

While assessing a patient in pain, a nurse knows that which of the following signs and symptoms support chronic as opposed to acute pain?

A) Blood pressure (BP) 116/84, pulse rate (P) 76, respiration rate (R) 18
B) Sudden sharp, stabbing pain
C) Dull, aching pain over past 7 months
D) Dilated pupils
E) Withdrawn with loss of appetite

Question 37

A nurse suspects that a patient is experiencing orthostatic hypotension. The patient's blood pressure is which of the following?

A) 20 mm Hg higher when sitting than when lying down
B) 20 mm Hg lower when sitting than when lying down
C) 20 mm Hg higher when lying down than when sitting
D) 20 mm Hg lower when standing than when sitting
E) 20 mm Hg higher when standing than when lying down

Question 38

While auscultating a patient's lungs, a nurse hears an audible, high-pitched crowing sound. The nurse identifies this sound as

A) Rhonchi.
B) Stridor.
C) Wheezes.
D) Rales.

Question 39

When taking a patient's temperature, a nurse understands that regardless of what route is used, the normal core temperature range is

A) 96.2°F to 99.4°F.
B) 97°F to 99.6°F.
C) 97°F to 100.2°F.
D) 98.6°F to 99.2°F.