Chapter 17 Vital Signs

Chapter 17  Vital Signs

Complete Chapter Questions And Answers
 

Sample Questions

Multiple Choice
Identify the choice that best completes the statement or answers the question.

____ 1. When asked why pain is considered the sixth vital sign the nurse explains to the 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.

____ 2. Upon entering the patient’s room, the nurse determines that he should check the vital signs
rather than delegating that task. Which of the following reasons would best justify the nurse’s
decision to not delegate the task?
A.
The patient has just ambulated to the bathroom.
B.
He has a nagging concern that something isn’t right.
C.
The patient is being discharged from the hospital.
D.
The patient has a long history of hypertension.

____ 3. The nurse understands that the 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.

____ 4. The nurse explains to the 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.

____ 5. The nurse expects that the blood pressure will increase in the patient
A.
Who avoids caffeine, nicotine, and sedentary lifestyle.
B.
Who is in top physical condition.
C.
Who has an increased blood volume, such as pregnancy.
D.
With a history of hypotension.

Chapter 17. Vital Signs
Answer Section

MULTIPLE CHOICE

1. ANS: D

Feedback
A
Effectiveness of pain control is not solely measured by changes in vital signs.
B
Pain does affect vital signs in some cases but is not the single reason for affecting vital signs.
C
Typically, in most cases acute pain will increase blood pressure but not to dangerous levels.
D
Pain is measured as a vital sign because it gives baseline data that serves as a warning that tissues are or can be damaged. Chapter Objective: Describe the six vital signs, their significance, and their normal ranges.

PTS: 1 REF: Chapter: 17 | Page: 344 OBJ: Chapter Objective: 17-2
KEY: Content Area: Reduction of Risk Potential | Integrated Process: Teaching and Learning | Client Need: Physiological Integrity/Reduction of Risk Potential/Vital Signs | Cognitive Level: Application

2. ANS: B

Feedback
A
Unless this is the first time a patient has been out of bed following a procedure, or a patient is having difficulty getting back to bed, the vital signs can be delegated.
B
If a nurse gets a “feeling” that something is wrong, that instinct should always be acted upon. Chapter Objective: Identify times when vital signs should be assessed.
C
Vital signs taken prior to leaving the hospital can be delegated in most cases.
D
A long history of hypertension does not necessarily indicate assessment of the blood pressure cannot be delegated.

PTS: 1 REF: Chapter: 17 | Page: 344 OBJ: Chapter Objective: 17-3
KEY: Content Area: Reduction of Risk Potential | Integrated Process: Nursing Process/Assessment | Client Need: Physiological Integrity/Reduction of Risk Potential/Vital Signs | Cognitive Level: Analysis

3. ANS: D

Feedback
A
The higher the stroke volume the higher the cardiac output.
B
Pain and fatigue do not directly result in a lowered cardiac output.
C
Congestive heart failure alone does not result in a low blood volume.
D
Weakened and damaged heart muscle does result in a lowered cardiac output. Chapter Objective: Outline the four circulatory qualities and how they determine blood pressure.

PTS: 1 REF: Chapter: 17 | Page: 346 OBJ: Chapter Objective: 17-5
KEY: Content Area: Physiological Adaptation | Integrated Process: Nursing Process/Assessment | Client Need: Physiological Integrity/Physiological Adaptation/Basic Pathophysiology | Cognitive Level: Comprehension

4. ANS: C

Feedback
A
Blood pressure alone does not measure blood volume.
B
Blood pressure measures the resistance within the arteries, not veins.
C
Blood pressure measures the amount of force blood places on arterial walls. Chapter Objective: Define key terms associated with assessment of the six vital signs.
D
The veins and arteries do not exert pressure on the heart.

PTS: 1 REF: Chapter: 17 | Page: 345 OBJ: Chapter Objective: 17-1
KEY: Content Area: Reduction of Risk Potential | Integrated Process: Teaching and Learning | Client Need: Physiological Integrity/Reduction of Risk Potential/Vital Signs | Cognitive Level: Application

5. ANS: C

Feedback
A
Caffeine, nicotine, and sedentary lifestyle may increase blood pressure, so avoidance of these should not increase blood pressure.
B
Patients who are exercising should gradually exhibit a decrease in blood pressure.
C
Pregnancy increases blood volume and blood pressure. Chapter Objective: Outline the four circulatory qualities and how they determine blood pressure.
D
Hypotension is low blood pressure.

PTS: 1 REF: Chapter: 17 | Page: 346 OBJ: Chapter Objective: 17-5
KEY: Content Area: Reduction of Risk Potential | Integrated Process: Nursing Process/Assessment | Client Need: Physiological Integrity/Reduction of Risk Potential/Vital Signs | Cognitive Level: Analysis