Chapter 4: General Inspection and Measurement of Vital Signs

Chapter 4: General Inspection and Measurement of Vital Signs

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

MULTIPLE CHOICE

 

1. Which body system does the nurse assess primarily by inspection?

a.	Respiratory
b.	Gastrointestinal
c.	Skin
d.	Cardiovascular

 

 

ANS:  C

 

	Feedback
A	The respiratory system is assessed primarily using auscultation, but also percussion and inspection when observing pale or cyanotic skin from hypoxia.
B	The gastrointestinal system is assessed primarily by auscultation and palpation, but also with inspection when looking at the contour of the abdomen.
C	Skin is assessed primarily using inspection, but also palpation.
D	The cardiovascular system is assessed primarily with auscultation and palpation, but also by inspection when looking at the color of extremities for evidence of perfusion or edema.

 

 

DIF:    Cognitive Level: Remember            REF:   37

TOP:   Nursing Process: Assessment

MSC:  NCLEX: Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

 

2. A patient is sitting slightly forward bracing his arms on his knees in a tripod position. This position is associated with which symptom?

a.	Abdominal pain
b.	Spinal deformity
c.	Back pain
d.	Breathing difficulty

 

 

ANS:  D

 

	Feedback
A	Positions used by patients with abdominal pain vary depending upon what organ is involved. For example, patients with appendicitis tend to lie very still; those with acute pancreatitis prefer the fetal position for pain relief.
B	Spinal deformity usually affects the patient’s gait or causes a slumped posture.
C	Back pain usually affects the patient’s gait or causes a slumped posture.
D	Breathing difficulty is associated with the tripod position, which allows maximal expansion of the muscles of respiration.

 

 

DIF:    Cognitive Level: Remember            REF:   37

TOP:   Nursing Process: Assessment

MSC:  NCLEX: Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

 

3. The temperature of a patient is measured every 6 hours at 6 AM, 12 PM, 6 PM, and 12 AM. Which temperature reading is expected to be low due to a normal variation?

a.	The measurement at 6 AM
b.	The measurement at 12 PM
c.	The measurement at 6 PM
d.	The measurement at 12 AM

 

 

ANS:  A

 

	Feedback
A	Early in the morning is the time of the lowest temperature of the day due to circadian rhythms.
B	A low temperature due to circadian rhythms is not expected at this time.
C	The highest temperature occurs in the late afternoon and early evening due to circadian rhythms.
D	A low temperature due to circadian rhythms is not expected at this time.

 

 

DIF:    Cognitive Level: Understand            REF:   38

TOP:   Nursing Process: Assessment

MSC:  NCLEX: Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

 

4. Which statement is correct regarding taking or interpreting axillary temperatures?

a.	Axillary temperatures should not be used in patients less than 2 years of age.
b.	Readings may be less accurate.
c.	The thermometer is left in place for no more than 3 minutes.
d.	The thermometer is placed in the axilla with the shoulder abducted.

 

 

ANS:  B

 

	Feedback
A	The axilla is a common site for temperature measurement on infants and children.
B	Multiple studies have shown temperature measurements at the axillary site are less accurate compared with alternative sites.
C	The thermometer is left in place until the audible signal occurs and the temperature appears on the screen.
D	Place the probe in the middle of the axilla, with the arm held against the body (adducted).

 

 

DIF:    Cognitive Level: Understand            REF:   39

TOP:   Nursing Process: Assessment

MSC:  NCLEX: Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments