Question 1

A 72-year-old woman is admitted to the hospital with pneumonia. Her baseline oral temperature is 97.2°F (36.2°C). On the second day, her temperature rises to 99.1°F (37.3°C). What is the most appropriate interpretation of this finding?

Accepted Answer

This temperature may represent a significant fever for this patient, given her lower baseline and age-related changes.

Question 2

Which of the following best describes the physiological mechanism by which the body increases heat production during a fever?

Accepted Answer

The hypothalamus increases the set point, triggering shivering and increased metabolism via epinephrine and norepinephrine release.

Question 3

A nurse is preparing to assess the blood pressure of an obese adult patient. The only available cuff is a standard adult size, which is too small for the patient’s arm. What is the most likely effect on the blood pressure reading?

Accepted Answer

The reading will be falsely high due to the cuff being too narrow.

Question 4

A patient is prescribed a medication that stimulates the sympathetic nervous system. Which change in pulse would the nurse most likely expect?

Accepted Answer

An increase in pulse rate and force of contraction.

Question 5

A nurse is teaching a patient how to use a home blood pressure monitor. Which of the following instructions is most important to ensure accurate readings?

Accepted Answer

Sit with your back and feet supported, arm at heart level, and avoid talking during the measurement.

Question 6

A patient’s blood pressure is measured at 120/80 mm Hg. What is the pulse pressure, and how is it calculated?

Accepted Answer

Pulse pressure is 40 mm Hg, calculated as $$120 - 80$$

Question 7

A nurse is assessing a patient who reports dizziness and lightheadedness upon standing. The nurse measures the patient’s blood pressure lying down, sitting, and standing. The standing blood pressure drops by 25 mm Hg systolic and 12 mm Hg diastolic within 3 minutes. What is the most accurate term for this condition?

Accepted Answer

Orthostatic hypotension

Question 8

Which of the following scenarios best illustrates the application of the auscultatory method for measuring blood pressure?

Accepted Answer

Inflating a cuff on the upper arm, using a stethoscope to listen for Korotkoff sounds over the brachial artery.

Question 9

A nurse is caring for a patient with a core body temperature of 33°C (91.4°F) after prolonged exposure to cold. Which of the following symptoms would the nurse most likely observe?

Accepted Answer

Poor coordination, slurred speech, and decreased respirations.

Question 10

A nurse is assessing a 4-year-old child’s temperature. Which site and method is most appropriate for this patient?

Accepted Answer

Axillary temperature using an electronic thermometer.

Question 11

A patient’s apical pulse is 98 beats/min, and the radial pulse is 84 beats/min. What is the pulse deficit, and what does it indicate?

Accepted Answer

Pulse deficit is 14 beats/min, indicating some heartbeats are not reaching the periphery.

Question 12

A nurse is evaluating a patient with a fever of 39.5°C (103.1°F) that has lasted for 4 weeks without an identified cause after a minimal diagnostic workup. Which term best describes this condition?

Accepted Answer

Fever of unknown origin (FUO)

Question 13

Which of the following factors would most likely cause a false elevation in a patient’s blood pressure reading?

Accepted Answer

Patient has just exercised and is talking during the measurement.

Question 14

A nurse is assessing a patient’s respirations and notes a rate of 28 breaths per minute, deep and regular. Which term best describes this pattern?

Accepted Answer

Hyperventilation

Question 15

A patient is prescribed a beta-adrenergic blocker for hypertension. What is the expected effect of this medication on vital signs?

Accepted Answer

Decreased heart rate and decreased blood pressure.

Question 16

A nurse is using a temporal artery thermometer to assess a patient’s temperature. Which of the following actions is most likely to result in an inaccurate (falsely high) reading?

Accepted Answer

Measuring over a head covering or wig.

Question 17

A nurse is caring for a patient with a history of heart failure who presents with a weak, thready peripheral pulse. Which of the following best describes the likely underlying cause?

Accepted Answer

Decreased cardiac output and peripheral perfusion.

Question 18

A patient is found to have a blood pressure of 88/54 mm Hg, feels dizzy, and has pallor and tachycardia. Which of the following is the most appropriate nursing action?

Accepted Answer

Immediately communicate the findings to the healthcare provider.

Question 19

A nurse is assessing a patient’s pulse and notes that the rhythm is irregular, with uneven intervals between beats. What is the correct term for this finding?

Accepted Answer

Dysrhythmia

Question 20

A nurse is caring for a patient with a core body temperature of 41.2°C (106.2°F). What is the most appropriate immediate intervention?

Accepted Answer

Rapidly cool the patient to prevent complications of hyperpyrexia.

Vital Signs: Foundations of Personal Health Assessment

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