Chapter 04: Vital Signs and Pain Assessment

Chapter 04: Vital Signs and Pain Assessment

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

MULTIPLE CHOICE

 

1. The pyrexia response is triggered by the production and release of:

a.	prostaglandins.
b.	endogenous pyrogens.
c.	hypothalamic enzymes.
d.	thyroid hormones.

 

 

ANS:  A

When microorganisms invade the body, pyrogens are released and travel to the hypothalamus. The pyrexia response is then triggered by the production and release of prostaglandins.

 

DIF:    Cognitive Level: Understanding (Comprehension)             REF:   p. 50

OBJ:   Nursing process—assessment          MSC:  Physiologic Integrity: Physiologic Adaptation

 

2. During respiration, the internal intercostals:

a.	increase the force of muscular contraction.
b.	decrease the lateral diameter during expiration.
c.	decrease the intrathoracic space.
d.	increase elastic recoil during expiration.

 

 

ANS:  B

The diaphragm is the dominant muscle during respiration. It contracts and pushes downward during inspiration to increase the intrathoracic space. The external intercostal muscles increase the AP diameter during inspiration and the internal intercostals decrease the lateral diameter during expiration.

 

DIF:    Cognitive Level: Understanding (Comprehension)             REF:   p. 50

OBJ:   Nursing process—assessment          MSC:  Physiologic Integrity: Physiologic Adaptation

 

3. The fifth vital sign is:

a.	pain.
b.	orientation.
c.	waist-to-hip ratio.
d.	body mass index (BMI).

 

 

ANS:  A

Pain, the universal distress signal, is now recognized as the fifth vital sign.

 

DIF:    Cognitive Level: Remembering (Knowledge)                    REF:   p. 50

OBJ:   Nursing process—assessment          MSC:  Physiologic Integrity: Physiologic Adaptation

 

4. The Joint Commission (TJC) requires that:

a.	pain be assessed on all discharges.
b.	repeated assessment of pain be limited to those patients who complain of pain.
c.	repeated intensity documentation be made of the course of pain relief for all patients.
d.	pain be assessed on surgical patients.

 

 

ANS:  C

TJC requires pain assessment on all admissions, repeated assessments for pain regardless of the initial complaint or surgical experience, and repeated intensity documentation of the course of pain relief for all patients.

 

DIF:    Cognitive Level: Understanding (Comprehension)             REF:   p. 50

OBJ:   Nursing process—assessment          MSC:  Physiologic Integrity: Physiologic Adaptation

 

5. The perception of pain:

a.	is the same across cultures.
b.	can be easily assessed in neonates.
c.	is predictable with the same circumstances.
d.	is affected by emotions and quality of sleep.

 

 

ANS:  D

The perception of pain is variable and is affected by emotions, cultural background, sleep deprivation, previous pain experience, and age. Perception of pain is different among different cultures. Neonates do feel pain, but perception of pain cannot be assessed in neonates. Each circumstance will provide different pain perception.

 

DIF:    Cognitive Level: Understanding (Comprehension)             REF:   p. 51

OBJ:   Nursing process—assessment          MSC:  Physiologic Integrity: Physiologic Adaptation