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Documenting Vital Signs

Questions and Answers


1.

Maria presents with c/o abdominal pain, nausea and vomiting. The physician requests that you obtain a
rectal temperature. Her temperature is 102.7. How do you document her temperature? T=102.7 (R)

2.
When you take Maria's blood pressue, her systolic pressure is 90 and her diastolic is 50. How do you chart her blood
pressure? BP=90/50

3.
Maria's respirations are 24. This is a normal range for respirations.
A. false
True
B.

o
False

4.
Correctly document Maria's respirations. The previous question stated that they are 24. R 24

5.
Maria has now begun to have diarrhea. It has been 45 minutes since she was given a Tylenol suppository for her
fever. The doctor asks you to evaluate her response to the Tylenol by rechecking her temperature. What method will
you use?
A.
Oral
B.

o
Axillary

C.

o
Rectal

D.

o
Aural

6.
The temperature recheck is 101.1. How should you document the temperature? 101.1 T

7.
Maria's pulse rate is 100. This is a normal pulse rate.
A.
True

B.

False

8.
How do you correctly document Maria's pulse of 100? P 100

9.
Martin is 6 months old. You have been tasked to obtain his height and weight. He will not remain still on the scale
and you are afraid that he will roll off. You improvise......you weigh his Mom and she is 165.3 pounds. You weigh
Mom again while she is holding Martin. Together they weigh 177.8 pounds. How do you document Martin's weight?
Wt 12.5 lbs

10.
To get Martin's height, you lay him on the exam table and mark the paper at the top of his head and his outstretched heel. You measure the distance between the marks and get 28 inches. Document his height. Ht 28
Ht 2ft 4 in

Anderson Nursing Assessment- Vital Signs, Pain


And Nursing Process

Questions and Answers


1.

The blood pressure cuff that is selected to use on the patient may provide an inaccurate result if the incorrect size is
chosen.
A.
True
B.

o
False

2.
______________ is the component of the nursing process in which the nurse makes the decision that the current
issue is resolved or requires further nursing interventions.
A.
Assessment
B.

o
Diagnosis

C.

Outcome /planning
D.

o
Interventions
o

E.

Evaluation

3.
General appearance includes which of the following components as part of the assessment? (Mark all that apply)
A.
Grooming
B.

o
Odor

C.

o
Skin color

D.

o
Conversive

E.

o
Nail polish

4.
Pain is what the patient says it is.
A.
True
B.

o
False

5.
The ___________ temperature is measured in the armpit.

6.
What scale would you use to assess pain in an alert and oriented adult patient?
A.
FLACCS scale
B.

o
FACES scale

C.

Numeric (1-10), verbal


D.

o
CPOT

7.
A care plan informs the physician what he needs to address with the patient an their family.
A.
True
B.

o
False

8.
The five vital signs are temperature, blood pressure, pulse, __________ and pain.

9.
An assessment must be completed on the patient prior to determining a nursing diagnosis.
A.
True
B.

o
False

10.
If the patient is clean and well dressed they are probably healthy
A.
True
B.

o
False

VITAL SIGNS Questions and Answers


1.

Ideal Oral temperature ___


A.
96.8
B.

o
98.6

C.

o
99.6

2.
Normal Pulse ___

A.

50-60
B.

o
60-100

C.

o
100-120

3.
Normal Respiration ___
A.
12-16
B.

o
12-20

C.

o
12-24

4.

Normal Systolic ___


A.
80-100
B.

o
90-110

C.

o
100-120

5.

Normal Diastolic ___


A.
50-60
B.

o
60-80

C.

o
80-89

6.
The process of temperature regulation in body is known as ___

A.

o
Thermostat

B.

o
Thermoregulation

C.

o
Hyperthymus

7.
Loss of heat through electromagnetic wave ____
A.
Radiation
B.

o
Convection

C.

o
Evaporation

8.
Transfer of heat through circulation of heat and water ___
A.
Evaporation
B.

o
Convection

C.

o
Radiation

9.
___ Occurs when water is converted into vapour and lost from the skin
A.
Radiation
B.

o
Evaporation

C.

o
Conduction

10.
___ is the process by which heat is transferred from warm to cool surface
A.
Radiation
B.

o
Conduction

C.

o
Convection

11.
Pyrexia means ___
A.
Coldness
B.

o
Shivering

C.

Abnormally high temperature

12.
Fever occurs in ___ phases
A.
1
B.

o
3

C.

o
5

13.
Hypovolemia is ___
A.
Fever
B.

o
Anemia
o

C.

Dehydration

14.
Fever producing substance are called ___
A.
Pathogens
B.

o
Pythons

C.

o
Pyrogens

15.
Hypothermia exists when temperature falls below ___ degree
A.
96.8 F
B.

o
98.6 F

C.

o
95.6 F

16.
Sever Hypothermia occurs when Temp drops below ___ degree
A.
80.4 F
B.

o
82.4 F

C.

o
84.2 F

17.
Contraction of heart can be called ___
A.
Blood Pressure
B.

o
Diastole

C.

o
Systole

18.
Resting Phase of heart is known as ___
A.
Diastole
B.

o
Systole

C.

o
Cardiac output

19.
Total quantity of blood pumped per minute ___
A.
Cardiac output
B.

o
Stroke Volume

C.

o
Heart Rate

20.
___ is the quantity of blood pushed out by each contraction.
A.
Cardiac output
B.

o
Systole

C.

o
Stroke Volume

21.
Feeling the pulse is called ___
A.
Auscultation

B.

Palpation
C.

o
Pulse Rate

22.
Listening the pulse with a stethoscope is ___
A.
Palpation
B.

o
Auscultation

C.

o
Evaluation

23.
___ is the exchange of gases between capillaries and body tissue cells
A.
Internal Respiration
B.

External respiration
C.

Pulmonary Ventilation

24.
Mechanical aspect of respiration in respiratory system ___
A.
Internal Respiration
B.

Pulmonary Ventilation
C.

External respiration

25.
Air taken in on inspiration 300-500ml is ___
A.
Breathing

B.

o
Ventilation

C.

o
Tidal Volume

26.
Peripheral chemo receptors in the ___ and ___ bodies simulate respiration.
A.
Aarotid, Cortic
B.

Carodine, Aerodine
C.

o
Carotid, Aortic

27.
Cessation of breath is called ___
A.
Apnea
B.

o
Eupnea

C.

o
Bradypnea

Questions and Answers


1.

_____ is reflected in the vital signs by indicating the status of the body's function, which is regulated through
homeostatis mechanisms and falling within certain normal ranges.
A.
Lifestyle
B.

o
Vital signs

C.

o
Homeostasis

D.

o
Health status

E.

None of the above

2.
How often are vital signs assessed in patients who are taking medications that affect cardiovascular or respiratory
function or who have had surgery? Every:

3.
True or false:A nurse can delegate to other healthcare personnel to do vital sign assessment of patients.
A.
True
B.

o
False

4.
Body temperature indicates the difference between the ____ of heat and the ____ of heat. (separate answers with a
space)

5.
Core body temperature is normally maintained within the rage of ____ degrees F to _____ degrees F. (separate
answers with a space)

6.
Core body temperature is highest at:
A.
Early morning
B.

o
Noon

C.

o
Late afternoon

D.

o
Evening

E.

o
Night
Discuss

7.

Core body temperature is ____ surface body temperature.


A.
Less than
B.

o
Higher than

C.

o
Equal to

D.

None of the above

8.
Core temperatures are not measured at:
A.
Tympanic site
B.

o
Rectal site

C.

o
Bladder

D.

o
Sublingual site

E.

Pulmonary artery site


Discuss

9.
Core body temperature is normally maintained within a rage of ____ degrees C and ____ degrees C. (separate
answers with a space)

10.
A newborn's temperature should be
A.
37 degrees Celcius (oral)

B.
37 degrees Celcium (axillary)

C.

37.7 degrees Celcius (rectal)


D.

36.8 degrees Celcius (axillary)


E.

36.8 degrees Celcius (rectal)

11.
A normal temperature for a child between 1-3 years of age is:
A.
37.7 degrees Celcius (axillary)
B.

36.8 degrees Ceclius (rectal)


C.

37.7 degrees Celcius (rectal)


D.

36.8 degrees Celcius (axillary)


E.

36 degrees Celcius (orally)

12.
The normal temperature for an adult is:
A.
37 degrees Celcius (axillary)
B.

37 degrees Celcius (oral)


C.

36 degrees Celcius (oral)


D.

37.7 degrees Celcius (oral)


E.

36.8 degrees Celcius (axillary)

13.
The average temperature of an adult older than 70 years of age is _____ degrees celcius orally.

Discuss

14.
The average pulse for a teen is
A.
80-180 bpm
B.

o
75-110 bpm

C.

o
80-140 bpm

D.

o
60-120 bpm

E.

o
60-100 bpm

15.
The primary source of heat in the body is _____

16.
____ is produced as a byproduct of metabolic activities that generate energy for cellular functions.
Discuss

17.
When additional heat is required to maintain balance, epinephrine and norepinephrine (sympathetic
neurotransmitters) are released and alter metabolism so that energy production ____ and heat production ____.
(separate answers with a space)

18.
Which hormone increases metabolism and heat production, but over a much longer time period than epinephrine and
norepinephrine.

19.
_____ is a response that increases the production of heat; it is initiated by the hypothalamus and results in muscle
tremours.

20.
______ occurs with shivering, causing "goose bumps" and reducing the size of the surface to minimize heat loss.
Discuss

21.
Shivering and piloerection are forms of:
A.
Heat loss

B.

o
Heat production

C.

Environmental temperature
D.

o
Fever

E.

None of the above

22.
Connections in the skin that remain open to allow heat to dissipate to the skin or close to retain heat in the body are
called

23.
Which of the following controls the opening and closing of the arteriovenous shunts in response to changes in core
body temperature and in environmental temperature.
A.
Autonomic nervous system
B.

Parasympathetic nervous system


C.

Sympathetic nervous system


D.

o
All of the above

E.

None of the above

24.
True or False:Heat production also occurs through warming and humidigying of inspired air and elimination of urine
and feces.
A.
True
B.

o
False

25.

Which group's body temperature changes more rapidly in response to both heat and cold air temperatures?
A.
Infants and children
B.

o
Older adults

C.

o
Women

D.

o
Men

E.

None of the above


Discuss

26.
Which group lose some thermoregulatory control and are at risk for harm from extremes of temperature?
A.
Infants and children
B.

o
Older adults

C.

o
Women

D.

o
Men

E.

None of the above


Discuss

27.
Which group tends to have more fluctuations in body temperature, probably due to the result of changes in
hormones/ The increase in progesterone secretion increases body temperature as much as 0.5F to 1.0F.
Discuss

28.
When one is exposed to extreme cold without adequate protective clothing, heat loss may be increased to the point
of _____, which can lead to serious illness or death.

29.
When one is exposed to extreme heat for long periods of time _____ may result, which can lead to serious illness or
death.

30.
When the body gives off waves of heat from uncovered surfaces, it is called

31.
____ occurs when oscillating fan blows currents of cool air across the surfaces of a warm body.

32.
The conversion of a liquid to vapour is called

33.
The transfer of heat to another object during direct contact is called _____

34.
An example of ____ is when the body transfers heat to an ice pack, causing the ice to melt.

35.
When a person has a normal body temperature it is called
A.
Afebrile
B.

o
Febrile

C.

o
Pyrexia

D.

o
Hyperpyrexia

E.

o
Hypothermia

36.
Two terms synonymous to "fever" are:(separate answers with a space)
Discuss

37.
A mild elevation in temperature might indicate a serious infection in infants younger than _____ of age who do not
have a well-developed temperture-control mechanism.
A.
2 months

B.

3 months
C.

o
6 months

D.

o
1 year

E.

o
2 years

38.
The difference between hyperthermia and pyrexia is: Fever occurs when the body temperature is raised without the
consent of the heat control centers. A hyperthermia occurs when the body sets the core temperatures to a higher
temperature, through the action of the pre-optic region of the hypothalamus.
A.
True
B.

o
False

39.
A temperature less than 95 degrees F is termed

40.
A temperature between 100.5 and 105 degrees F is termed

41.
A temperature above 105.8 is termed

42.
In older adults, fever may be an [early or later] sign of illness.
Discuss

43.
When the set point is increased, as in fever, the hypothalamus inatiates
A.
Sweating
B.

o
Shivering

C.

o
Vasoconstriction
o

D.

A and C
E.

o
B and C
Discuss

44.
True or False:Most fevers are not self-limiting.
A.
True
B.

o
False

45.
Hyperthermia differs from fever in that the hypothalamic set point is changed, and in situations of extreme heat
exposure the mechanisms that control the body temperature are ineffective.
A.
True
B.

o
False

46.
If the cause of any type of fever is difficult to determine, it is often diagnosed as

47.
Drugs, such as aspirin or acetaminophen, are believed to lower the elevated set point regulated by the hypothalamus
are called _____. They do not affect body temperature when it is within normal range.

48.
Apart from administering antipyretic drugs, name one possible nursing intervention used to lower body temperature.
Discuss

49.
Which type of fever is defined as: the body temperature alternates regularly between a period of fever and a period of
normal or subnormal temperature.

50.
Which type of fever is defined as: The body temperature fluctuates several degrees more than 2 degrees C (3.6 F)
above normal but does not reach normal betwenn fluctuations.

51.
Which type of fever is defined as: the body temperature remains consistently elevated and fluctuates less than 2
degrees C (3.6 F)
Discuss

52.

What terms used to describe fever is defined as: The fever returns to normal suddenly
Discuss

53.
What term that describes fever is defined as: The fever retruns to normal gradually.

54.
Non-mercury glass thermometers may be either spirit-filled (using a petroleum-based liquid) or alcohol-based; the
bulb contains a liquid that _____ with heat and rises within the stem.

55.
Some disposable single-use thermometers, that are commonly applied to abdomen or forehead, often of young
children and toddlers, have a temperature-senstive patch or tape what changes ______
Discuss

56.
This type of thermometer is swiped across the skin over the respective artery, taking 1000 readings per second and
selecting the most accurate.
A.
Carotid artery thermometer
B.

Subclavian artery thermometer


C.

Maxillary artery thermometer


D.

Temporal artery thermometer


E.

None of the above

57.
Many enironmental and physiologic processes occur in repeated cycles of time, such as _____ _______ which is 24hour intervals.

58.
A throbbing sensation that can be palpated over a peripheral artery or auscultated over the apex of the heart is called
a

59.
The pulse is regulated by the autonomic nervous system through the cardiac sinoatrial (SA) node. ______ stimulation
of the SA node via the vagus nerve decreases the heart rate, and _______ stimulation of the SA node increases the
heart rate and force of contraction.
A.
Sympathetic; somatic

B.

Sympathetic; parasympathetic
C.

Parasympathetic; sympathetic
D.

Parasympathetic; somatic
E.

None of the above


Discuss

60.
Parasympathetic stimulation of the SA node via the ______ nerve decreases the heart rate.

61.
_______ mechanisms attempt to maintain a sufficient supply of blood to the cells at all times.

62.
Normal pulse rate for adolescences and adults rangers from _____ to _____ beats per minute.
A.
60 - 90 bpm
B.

o
50 - 100 bpm

C.

o
60 - 120 bpm

D.

o
50 - 110 bpm

E.

None of the above


Discuss

63.
What is the term used to describe decreased cardiac filling time, which, in turn, decreases stroke volume and cardiac
output, due to rapid rate.
Discuss

64.
Tachycardia is a pulse rate between ____ and ___ bpm. (separate answers with a space)

65.
Which of the following does not contribute to tachycardia.

A.

o
Medications

B.

Elevated temperature
C.

Increased blood pressure


D.

o
Anemia

E.

Prolonged application of heat

66.
What is the term used to describe a pulse rate below 60 bpm

67.
WHich of the following doesn't contribute to bradycardia
A.
Obesity
B.

o
Medications

C.

o
Being alseep

D.

o
Being a man

E.

None of the above


Discuss

68.
Bradycardia is a pulse rate below ___ bpm

69.
Sinus bradycardia results from the ____ ____ creating a slower-than-normal impulse rate.

70.
Sinus bradycardia is not caused by which of the following:
A.

TImes when metabolic needs are decreased


B.

o
During sleep

C.

o
Severe pain

D.

o
Hyperthermia

E.

o
Vagal stimulation

71.
Emergency treatment for severe bradycardia is the administration of _____ intravenously to block vagal stimulation
and to restore normal heart rate.
Discuss

72.
The pulse amplitude describes the quality of the pulse in terms of its fullness and reflects the strength of _____
contraction
A.
Right ventricle
B.

o
Left ventricle

C.

o
Aorta

D.

o
Right atrium

E.

o
Left atrium
Discuss

73.
An irregular pattern of heartbeats is called a

Questions and Answers


1.

Vital signs includes, blood pressure, Pulse, Temp. Resp. rate & Oxygen saturation.
A.

True
B.

o
False

2.
Where is temperature is regulated?
A.
Hypothalamus
B.

o
Skin

C.

o
Heat & Cold

D.

By what a person wear

3.
What is the normal range of temperature?
A.
36.6-37.5 c
B.

o
34-36 c

C.

o
34.6-36 c

D.

o
35.6-38 c

4.
What is the normal pulse rate?
A.
12-20
B.

o
15-20

C.

o
60-100

D.

o
50-80

5.
A weak pulse is rated as
A.
0
B.

o
1+

C.

o
2+

D.

o
3+

E.

o
4+

6.
A patient have a pulse rate of 102, resp. rate of 25, a B/P of 139/90 and a temp. of 103 F. As a nurse which will you
assess first?
A.
B/P of 139/90
B.

o
Pulse of 102

C.

o
Resp. rate of 25

D.

o
Temp. of 103 F

7.
What is the maximum of oxygen can you give a patient with COPD?
A.
2 L/min
B.

o
10 L/min

C.

o
4 L/min

D.

o
6 L/min

8.
Blood pressure is the force against the aterial wall
A.
True
B.

o
False

9.
A person that is dehydrated will experience a low B/P
A.
True
B.

o
False

10.
What factor does not influence Resp. rate?
A.
Age
B.

o
Gender

C.

o
Smoking

D.

o
Medication

E.

o
Pain

11.
COPD regulation is by hypoxemia via chemoreceptors in the brain
A.

True
B.

o
False

12.
Eupnea is another word for difficulty breathing
A.
True
B.

o
False

13.
Pulse deficit is the difference between the apical and radial rate
A.
True
B.

o
False

14.
A patient has a radial pulse of 65 & a apical rate of 66, What is the pulse deficit?
A.
0
B.

o
1

C.

o
1+

D.

o
131

15.
A patient with a Temp. of 104 F and a damage hypothalamus, will you give antipyretic to lower the temperature?
A.
True
B.

o
False

Questions and Answers


1.

Apnea can be best described as


A.
Slow breathing
B.

A condition which a person must adjust their position in order to breathe


C.

o
Fainting

D.

None of the above

2.
A change in one or more of the vital signs could indicate a change in the overall health of a patient
A.
True
B.

o
False

3.
Check which vital signs are abnormal in a healthy 32 year old male: T: 103 F, PR: 90, RR: 44, B.P: 112/76 mmHG
A.
Temperature
B.

o
Pulse rate

C.

o
Respiratory rate

D.

o
Blood pressure

4.
A patient with vertigo would have dizziness and feel the sensation of the room spinning
A.
True

B.

False

5.
All of the following are characteristics the medical assistant should note while measuring a pulse
A.
Rate
B.

o
Rhythm

C.

o
Volume

D.

o
All of the above

6.
Anthropometric measurements include the following EXCEPT
A.
Weight
B.

o
Height

C.

o
Body mass index

D.

None of the above

7.
The blood pressure cuff has to be deflated between readings
A.
True
B.

o
False

8.
Body temperature is regulated by the hypothalamus
A.
True

B.

o
False

9.
Convert the following weight 145 lb= ___________kg use this conversion tools *make sure you put the unit of
measurement after the conversion... for example..________lb or kg 1kg= 2.2lb 1lb= 0.45 kg

10.
If a bedridden patient has chills and shivering you would expect the body temp to be decreased
A.
True
B.

o
False

11.
The systolic pressure may be checked by the radial pulse method if the medical assistant is unable to auscultate the
patient's blood pressure
A.
True
B.

o
False

12.
Which of the following can affect a patient's blood pressure reading
A.
Caffeine
B.

o
Exercise

C.

Traveling time to clinic


D.

o
All of the above

13.
Pre-hypertension can be considered a normal physiological process that doesn't need any further investigation
A.
True

B.

False

14.
Hyperlipidemia is an over production of which substance in one's blood?
A.
Carbohydrates
B.

o
Protein

C.

o
Fat

D.

None of the above

15.
If a pulse is consistently high above 100 bpm, then this pulse is said to be
A.
Bradycardic
B.

o
Tachypneic

C.

o
Tachycardic

D.

None of the above

16.
120/80= the second number which stands for the second tapping sound is called
A.
Systolic
B.

o
Diastolic

C.

o
Both
o

D.
None of the above

17.
Which is NOT a cardinal vital sign
A.
Temp
B.

o
Pulse

C.

o
Respiration

D.

None of the above

18.
Diastolic pressure is explained by
A.
Contraction
B.

o
Relaxation

C.

o
Both

D.

None of the above

19.
How long should the pulse be counted for the most accurate results?
A.
15 seconds multiplied by 4
B.

30 seconds multiplied by 2
C.

o
60 seconds

D.

o
45 seconds

20.
Atherosclerotic Plaques can lead to hypertension
A.
True
B.

o
False

21.
The following explains systolic pressure
A.
Relaxation
B.

o
Contraction

C.

o
Both

D.

None of the above

o
o

22.
Match the following pulse sites
A. apical
A.
Select a Match

B. brachial
B.

o
o

Select a Match

23.
The optimal blood pressure according to the JNC guidelines is
A.
At 120/80
B.

o
More than 120/80

C.

o
Less than 120/80
o

D.
None of the above

24.
A 27 year old male comes in for an annual physical. Jasmine the medical assistant student comes in reads his blood
pressure and reads at 140/95. One can say this patient is
A.
Hypertensive
B.

Suffering from white coat syndrome


C.

o
Normal

D.

None of the above

25.
The following blood pressure reading : 90/60, most likely resembles which type of blood pressure?
A.
Hypertensive
B.

o
Normotensive

C.

o
Hypotensive

D.

None of the above

26.
A 33 year old female tri-athlete is very well conditioned. We expect her pulse rate to be;
A.
High
B.

o
Very high

C.

o
Low
o

D.
None of the above

27.
If one palpates a pulse on the wrist underneath the thumb, this pulse is called the
A.
Ulnar
B.

o
Brachial

C.

o
Apical

D.

None of the above

28.
120/80= This first number which corresponds to the first tapping sound is called the
A.
Diastolic
B.

o
Systolic

C.

o
All of the above

D.

None of the above

29.
A 23 year old female has a temperature reading of 102 F, this is reading is said to be
A.
Afebrile
B.

o
Febrile

C.

o
Normal
o

D.
None of the above

30.
A 75 year old female had diffuclty recovering from the flu and developed Pneumonia as a consequence, the doctor
listened to her breath sounds and found the following sound
A.
Apnea
B.

o
Arrhythmia

C.

o
Rales

D.

None of the above

31.
A patient in good health comes to the clinic for a physical. Her temperature is elevated and reads at 101 C. What
could be the reason for the sudden rise in temp?
A.
Cold weather
B.

Drinking hot tea before the appointment


C.

o
Eating ice cream

D.

None of the above

32.
Malnourishment could be a cause of delayed growth in a child
A.
True
B.

o
False

33.
A good pulse site is the palpation of the ulnar artery
A.
True

B.

False

34.
Palpating the dorsalis pedis artery pulse is a great method in evaluating blood flow to the brain
A.
True
B.

o
False

35.
A diet low in sodium is a great way to reduce blood pressure
A.
True
B.

o
False

36.
Which would cause hyperlipidemia?
A.
Diet high in protein
B.

o
Diet high in carbs

C.

o
Diet high in fat

D.

None of the above

o
o

37.
Match the palpation sites
A. popliteal
A.
Select a Match

B. dorsalis pedis
B.

o
o

Select a Match

38.
Match the vital signs with the appropriate terms
A. Temp: 104 F

A.

Select a Match

B. Temp: 97 F
B.

o
o

Select a Match

o
o

39.
Match the vital signs with the appropriate terms
A. BP: 120/80
A.
Select a Match

B. BP: 119/79
B.

o
o

Select a Match

o
o

40.
Match the vital signs with the appropriate terms RR= respiratory rate
A. RR: 44
A.
Select a Match

o
o

B. RR: 13
B.
Select a Match

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