Test Bank for Foundations and Adult Health Nursing, 5th Edition: Barbara Christensen

Test Bank for Foundations and Adult Health Nursing,

5th Edition: Barbara Christensen

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Chapter 11: Vital Signs
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc.

MULTIPLE CHOICE

1. The part of the body that maintains a balance between heat production and heat loss,
regulating body temperature, is the
1. thymus.
2. thyroid.
3. hypothalamus.
4. adrenals.
ANS: 3
Body temperature is regulated by the hypothalamus.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 238

OBJ: 2 TOP: Vital signs KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A

2. The nurse is aware that body temperature that remains relatively constant is the
1. surface.
2. rectal.
3. oral.
4. core.
ANS: 4
The core body temperature remains relatively constant.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 238

OBJ: 1 TOP: Vital signs KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity

3. The nurse uses cooling techniques to keep the body temperature below 105° F because such
elevated temperature can
1. cause excessive thirst.
2. cause excessive perspiration.
3. damage body cells.
4. increase heart rate.
ANS: 3
If temperature exceeds 105° F, normal body cells may be damaged.

PTS: 1 DIF: Cognitive Level: Application REF: Page 243

OBJ: 1 TOP: Vital signs KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity

4. The emergency department nurse quickly assesses the temperature of an unconscious patient
who has been outside all night in below-freezing temperatures. The nurse is aware that death
can occur if the temperature falls below
 1. 95.2° F.
2. 93° F.
3. 93.2° F.
4. 90.8° F.
ANS: 3
Death can occur if temperature falls below 93.2° F.

PTS: 1 DIF: Cognitive Level: Application REF: Page 243

OBJ: 2 TOP: Vital signs KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity

5. The nurse reminds the aide that the comatose patient’s temperature should not be assessed
by the mode of
1. oral.
2. tympanic.
3. rectal.
4. axillary.
ANS: 1
Oral temperature is not obtained on a comatose patient.

PTS: 1 DIF: Cognitive Level: Application REF: Page 243

OBJ: 3 TOP: Vital signs KEY: Nursing Process Step: Assessment
MSC: NCLEX: Safe | Effective Care Environment

6. The nurse explains to a patient that his fever that rises and falls but never returns to normal
is classified as
1. constant.
2. intermittent.
3. remittent.
4. elevated.
ANS: 3
A remittent fever temperature never returns to normal.

PTS: 1 DIF: Cognitive Level: Application REF: Page 243

OBJ: 3 TOP: Remittent fever
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

7. Using the tympanic thermometer for a child, the nurse will tug the ear pinna
1. upward and back.
2. parallel.
3. downward and back.
4. upward and forward.
ANS: 3
Using the tympanic thermometer for a child, the nurse will tug the ear pinna down and back.

PTS: 1 DIF: Cognitive Level: Application

REF: Page 242 | Skill 11-1 OBJ: 3
 TOP: Tympanic thermometer for a child KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity

8. In order to assure optimum reception from a stethoscope, the nurse will place the earpieces
pointing
1. backward.
2. parallel to the ears.
3. toward the face.
4. downward.
ANS: 3
To ensure the best reception of sound, place earpieces pointing toward the face.

PTS: 1 DIF: Cognitive Level: Application REF: Page 246

OBJ: 3 TOP: Vital signs KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity

9. The nurse uses the diaphragm of the stethoscope to best assess

1. carotid sounds.
2. lung sounds.
3. vascular sounds.
4. low-pitched sounds.
ANS: 2
Lung sounds are auscultated by using the diaphragm of the stethoscope.

PTS: 1 DIF: Cognitive Level: Application REF: Page 246

OBJ: 3 TOP: Stethoscope use
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity

10. The nurse explains that the pulse, the expansion and contraction of an artery, is produced by
contraction of the
1. right atrium.
2. right ventricle.
3. left atrium.
4. left ventricle.
ANS: 4
Expansion and contraction of an artery are caused by the ejection of blood from the left
ventricle.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 246

OBJ: 10 TOP: Vital signs KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity

11. When assessing vital signs on a 40-year-old male, the nurse identifies a pulse rate of 120.
This pulse is
1. normal.
2. bradycardic.
 3. dysrhythmic.
4. tachycardic.
ANS: 4
If the pulse is faster than 100 beats per minute, this is tachycardia.

PTS: 1 DIF: Cognitive Level: Application REF: Page 246

OBJ: 1 TOP: Tachycardia KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity

12. The patient’s pulse is below 60. Because the nurse is aware that the patient is not receiving
digitalis, the nurse believes that the bradycardia might be caused by
1. low exercise tolerance.
2. unrelieved severe pain.
3. excessive bedrest.
4. a prone position.
ANS: 2
Bradycardia can result from unrelieved severe pain.

PTS: 1 DIF: Cognitive Level: Application REF: Page 246

OBJ: 10 TOP: Bradycardia KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity

13. The nurse, when wishing to assess a peripheral pulse quickly, selects the
1. radial.
2. brachial.
3. carotid.
4. pedal.
ANS: 3
The carotid site is the best for finding a pulse quickly.

PTS: 1 DIF: Cognitive Level: Application REF: Page 247

OBJ: 5 TOP: Carotid KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity

14. The nurse explains that the exchange of carbon dioxide and oxygen that takes place at the
alveolar level is termed
1. tachypnea.
2. internal respiration.
3. external respiration.
4. bradypnea.
ANS: 2
Internal respiration is the exchange of gas at the alveolar level.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 252

OBJ: 1 TOP: Internal respiration
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
Test Bank for Foundations and Adult Health Nursing, 5th Edition: Barbara Christensen

15. Because the nurse suspects a cardiac arrhythmia, she is concerned with the findings of an
apical rate of 88 and the radial rate of 80. The difference between the two rates is termed
1. pulse pressure.
2. unequal pulses.
3. pulse deficit.
4. tachycardia.
ANS: 3
The difference between radial and apical pulses is called a pulse deficit.

PTS: 1 DIF: Cognitive Level: Application REF: Page 251

OBJ: 1 TOP: Pulse deficit KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity

16. The nurse is alarmed when a patient with a severe head injury of the occipital lobe has a
respiratory rate of 10, as she is aware that this may indicate an injury to the
1. cerebellum.
2. medulla oblongata.
3. cortex.
4. cerebrum.
ANS: 2
Rate of respiration is controlled by the medulla oblongata.

PTS: 1 DIF: Cognitive Level: Application

REF: Page 253 | Box 11-10 OBJ: 2 TOP: Respiratory rate
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

17. The nurse describes the respiration of a patient who is demonstrating pursed-lip breathing,
flared nostrils, and retractions as
1. tachypnea.
2. stertorous.
3. dyspnea.
4. Cheyne-Stokes.
ANS: 3
The patient who is using ancillary muscles to breathe is exhibiting dyspnea.

PTS: 1 DIF: Cognitive Level: Application REF: Page 253

OBJ: 2 TOP: Dyspnea KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity

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