Chapter 14: Vital Signs

Chapter 14: Vital Signs

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

MULTIPLE CHOICE

1. Lucas is a nursing student who is obtaining Mrs. Elliott’s vital signs. Mrs. Elliott has gone to the clinic seeking help because she is having chest pain. Which of the following vital signs are most important for Lucas to obtain?

ANS:   D

The cardinal vital signs are temperature, pulse, respiration, blood pressure, and oxygen saturation. A sixth vital sign, assessment of pain, is a standard of care in health care settings. Frequently pain and discomfort are the signs that lead a patient to seek health care. Therefore assessing a patient’s pain helps a nurse understand the patient’s clinical status and progress.

PTS:    1                      DIF:    Cognitive Level: Analysis                  REF:    260

OBJ:    Accurately assess body temperature, pulse, respiration, oxygen saturation, and blood pressure       TOP:            Nursing Process: Assessment

MSC:   Client Needs: Physiological Integrity

2. Upon a patient’s admission to the nursing unit, the registered nurse delegated to the nursing assistive personnel to take her vital signs. What is the registered nurse’s responsibility regarding delegating this task?

ANS:   C

When caring for a patient, the nurse is responsible for vital sign measurement. A nurse may delegate the measurement of selected vital signs (e.g., stable patients) to nursing assistive personnel. However, it is the nurse’s responsibility to review vital sign measurements, interpret their significance, and make decisions about interventions.

PTS:    1                      DIF:    Cognitive Level: Analysis                  REF:    260

OBJ:    Correctly delegate vital sign measurement to nursing assistive personnel

TOP:    Nursing Process: Assessment

MSC:   Client Needs: Safe and Effective Care Environment

3. A 36-year-old African American patient has been admitted to the hospital with diabetic ketoacidosis. The nurse who is admitting him notes that his blood pressure is 164/98. Which of the following should the nurse do next?

ANS:   C

Know the patient’s usual range of vital signs. A patient’s usual values sometimes differ from the standard range for that age or physical state. Use the patient’s usual values as a baseline for comparison with findings taken later.

PTS:    1                      DIF:    Cognitive Level: Analysis                  REF:    260

OBJ:    Accurately assess body temperature, pulse, respiration, oxygen saturation, and blood pressure       TOP:            Nursing Process: Assessment

MSC:   Client Needs: Safe and Effective Care Environment

4. A man has been taken to the emergency department after passing out while repairing the roof on his house. The temperature outside is 96° F and his skin is warm and dry. How should the nurse obtain his temperature?

ANS:   B

Sites reflecting core temperature are more reliable indicators of body temperature than sites reflecting surface temperature, such as the armpit or axillae.

PTS:    1                      DIF:    Cognitive Level: Analysis                  REF:    265

OBJ:    Explain variations in techniques used to assess vital signs in an infant, a child, and an adult          TOP:            Nursing Process: Assessment

MSC:   Client Needs: Safe and Effective Care Environment

5. Nancy is a 6-year-old who was taken into the hospital after having a seizure at home. Nancy’s mother tells the nurse that she has been ill for the past week and has had a fever with nausea and vomiting. Nancy’s mother believes that the seizure was caused by a fever of 99.5° F, which Nancy had during the course of her illness. What is the nurse’s best response?

ANS:   B

Dehydration and febrile seizures occur during rising temperatures of children between 6 months and 3 years of age. Febrile seizures are unusual in children older than 5 years of age.

PTS:    1                      DIF:    Cognitive Level: Analysis                  REF:    262

OBJ:    Discuss physiological changes associated with fever

TOP:    Nursing Process: Assessment

MSC:   Client Needs: Safe and Effective Care Environment