Chapter 21 Measuring Vital Signs

Chapter 21  Measuring Vital Signs

Complete Chapter Questions And Answers
 

Sample Questions

MULTIPLE CHOICE

1. The nurse would anticipate a patient diagnosed with damage to the hypothalamus after suffering a head injury from a fall to exhibit:
a.
a blood pressure elevation.
b.
a temperature abnormality.
c.
a decrease in pulse rate.
d.
depressed respirations.

ANS: B
The hypothalamus, which is located between the cerebral hemispheres, controls body temperature. Any damage to the hypothalamus prevents the body from regulating its temperature.

DIF: Cognitive Level: Comprehension REF: p. 344 OBJ: Theory #1
TOP: Vital Signs: Temperature KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

2. The nurse documents vital signs on a newly admitted patient as: “blood pressure is 148/94 mm Hg, the pulse is 80 beats/min, and the respirations are 16 breaths/min.” The nurse would record the pulse pressure as:
a.
14 mm Hg.
b.
54 mm Hg.
c.
64 mm Hg.
d.
80 mm Hg.

ANS: B
In calculating pulse pressure, take the difference between the systolic and diastolic pressures (ie, 148 – 94 = 54).

DIF: Cognitive Level: Analysis REF: p. 364
OBJ: Clinical Practice #4 TOP: Vital Signs: Blood Pressure
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

3. A patient has been admitted with hypothermia after lying unconscious overnight in an unheated apartment. The most appropriate route to assess the patient’s core temperature would be:
a.
rectal.
b.
tympanic arterial thermometer.
c.
axillary.
d.
tympanic.

ANS: D
The same blood vessels serve the hypothalamus and the tympanic membrane, so the tympanic temperature is an excellent indicator of core body temperature, although it can be affected by ear wax.

DIF: Cognitive Level: Application REF: p. 348
OBJ: Theory #3 | Clinical Practice #1 TOP: Vital Signs: Temperature
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

4. The nurse would document a patient as being febrile if the patient’s temperature was over:
a.
99.5° F
b.
99.8° F
c.
100° F
d.
100.5° F

ANS: D
A patient with a temperature above the normal range (100.2° F) is called febrile.

DIF: Cognitive Level: Knowledge REF: p. 349 OBJ: Theory #3
TOP: Vital Signs: Temperature KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

5. To ensure an accurate reading when using a glass oral thermometer, it is necessary to:
a.
rinse the thermometer with water.
b.
wipe the thermometer with alcohol.
c.
shake down the galinstan alloy to below normal.
d.
dry the thermometer with a dry cotton ball.

ANS: C
Oral thermometers remain at the last reading until they are shaken down; therefore, for accuracy, the thermometer must be below normal range before using.

DIF: Cognitive Level: Application REF: p. 351
OBJ: Clinical Practice #1 TOP: Vital Signs: Temperature
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort