Republic of the Philippines

UNIVERSITY OF NORTHERN PHILIPPINES

Vigan City
Vital Signs

Name: ________________________________________________ Yr. & sec:___________ Date:__________ Score:__________

PART I. Instructions: Select the correct answer for each following question. ENCIRCLE the letter that
corresponds your answers. Strictly no erasures and superimpositions.

SCENARIO: Jack, a 78-year-old man with Dementia has been assigned to you. He fell out of his bed and sprained his
wrist. He is diabetic and suffers from left-sided weakness due to a stroke. He requires total care and assistance with
everything he does. He has dentures. He can no longer walk alone, feed himself, bathe or dress himself, and he is
incontinent of urine and stool. His vital signs are to be monitored q 4 hrs.

1. The taking of Jack’s vital signs includes

a. Temperature, blood pressure, respirations. and pulse
b. blood pressure, respirations, pulse and ROM
c. temperature, I&O, respirations, pulse and blood pressure
d. All of the above

2. When taking Jack’s blood pressure, you should make certain that
a. The cuff is the correct size
b. Jack is lying on his left side
c. The cuff is positioned dependent to his elbow
d. The cuff is pumped to at least 20 mm above his baseline b/p

3. The most accurate temperature is obtained when taken

a. Under the arm
b. Rectally
c. At the groin
d. In the ear

4. When counting the pulse rate, you may use the pulse at what points?
a. The carotid artery
b. The radial artery
c. The apical area of the heart via the chest using a stethoscope
d. All of the above

5. While assessing Jack’s temperature, you note that it is 101.2 degrees. What is your FIRST action?
a. Notify your supervisor
b. Call the doctor
c. Wait the appropriate amount of time and take the temperature again
d. Have a co-worker check your work.

6. You can count respirations while

a. Taking Jack’s b/p
b. Counting Jack’s pulse
c. Taking his temperature
d. None of the above

7. When assessing Jack’s respirations, you should

a. Count the number of times his chest rises and falls in one minute
b. Auscultate his chest
c. Observe whether Jack is breathing easily or seems to be having difficulty
d. All of the above

8. If Jack’s 3-year-old granddaughter was visiting and was watching you take her grandfather’s vital signs and became
curious about how you would take hers; you might explain to her that
a. You would do it on the arm but with a smaller cuff
b. You would do it on her thigh but with a smaller cuff
c. You would do it on her ankle using a smaller cuff
d. All of the above.

SITUATIONS: Vital signs are measurements of the body's most basic functions. They are very useful in detecting and
monitoring medical problems.
9. Which of the following statements about fever is not true.
a. Fever is a sign of illness
b. It is reflected through an increase of body temperature
c. It does not do anything to defend the body.
d. It is the same as pyrexia or hyperthermia
10. Which of the following are true about temperature readings?
a. Rectal readings are 1 degree Fahrenheit lower than oral readings
b. Rectal readings are 1 degree Fahrenheit higher than oral readings
c. Axillary readings are 1 degree Fahrenheit higher than oral readings
d. Axillary readings are 1 degree Fahrenheit lower than oral readings

11. 96.0 to 99.5 degrees Fahrenheit is the normal temperature range of which age group?
a. Neonate
b. Toddler
c. Adolescent
d. Middle adult

12. A rise in 1-degree Fahrenheit of temperature will increase the pulse rate by how many beats per minute?
a. 3
b. 5
c. 4
d. 6

13. The following traits are typical among the older: (SATA)
a. Decreased heart rate at rest
b. heart sounds are muffled
c. libido is normally heightened
d. infection is often afebrile
e. skin is more fragile.

14. Volume of pulse

a. Amount of blood that circulates through the cardio-pulmonary system
b. Refers to amount of blood pushing against the artery of the wall with each beat.
c. Amount of lubs and dubs that we hear every time we expire and inspire
d. Number of beats that the heart exerts every time we breath

15. In order to ensure correct placement, how should a tympanic thermometer be inserted into an adult’s ear to get a
correct reading?
a. Figure-8 fashion
b. Pulling pinna upward
c. Perpendicular to the head
d. Pulling pinna downward

16. Pulse is a rhythmic beating in the body that signifies regular, recurrent expansion and contraction of an artery
produced by the waves of pressure that are caused by ejection of blood from which part as it contracts?
a. Right ventricle
b. Left ventricle
c. Left atrium
d. Right atrium

17. Major parts of stethoscope. (SATA)

a. Tubing
b. Chest piece
c. Binaurals
d. Earpieces

18. When measuring the rectal temperature of an adult, how deep would the thermometer probe be inserted into the
rectum?
a. 1.5 cm
b. 1.5 inches
c. 0.5 inches
d. 2.5 inches

19. Possible causes of bradycardia. (SATA)

a. Supine position
b. Jogging
c. Pain
 d. Beta blockers

20. The most appropriate position in obtaining a rectal temperature for an adult would be:
a. Supine
b. Fowler’s
c. Sim’s
d. Lateral

21. The most appropriate definition of Vital Signs

a. Physiology and anatomy
b. Signs and symptoms of a disease
c. An indication of basic body functioning
d. A part of human composition

22. Pulse rate slower than 60 beats per minute

a. CVA
b. Tachycardia
c. Bradycardia
d. Orthopnea

23. Possible causes of Tachycardia. (SATA)

a. Epinephrine
b. Hemorrhage leading to hypovolemia
c. Unrelieved severe pain
d. Shock

24. Upon admission, the most appropriate person to check on a patient’s vital signs would be:
a. NA
b. RN
c. RRT
d. RPT

25. Which time of the day would we have the lowest temperature reading?
a. 8 pm to 12 mn
b. 1 am to 4 am
c. 4 pm to 6 pm
d. 4 am to 6 am

26. An instrument placed against a patient’s chest to hear both lung and heart sounds.
a. Sphygmomanometer
b. Stethoscope
c. Telescope
d. Otoscope

27. The difference between the Bell and the Diaphragm portions of the chestpiece in a stethoscope are the following:
a. Bell transmits high pitched sounds
b. Bell and Diaphragm have the same shape
c. Diaphragm is circular and flat surfaced, bell is bowl shaped
d. Bell is circular and flat surfaced, diaphragm is bowl shaped

28. When temperatures with baseline and normal temperature ranges are compared, what is normally revealed?
a. Accurate vital signs
b. Medical history of patient
c. The need to repeat the reading
d. Presence of abnormalities

29. To ensure the best reception of sound, the earpieces of the stethoscope should follow the contour of the ear canal,
pointing where?
a. Perpendicular to the occiput
b. Towards your face when the stethoscope is in place
c. Parallel to the temporal lobe of the head
d. Away from your face when the stethoscope is in place

30. When an infant is in a side-lying position, using an electronic axillary temperature, what kind of temperature would
the lower axilla record?
a. Higher temperature
b. Variable temperature
c. Consistent temperature
 d. Lower temperature

31. Constant, remittent and intermittent are classification of:

a. Anxiety
b. Pain
c. Fever
d. Headache

32. Older adults have an increase in systolic pressure related to what?

a. Decreased vessel elasticity
b. Diminished vessel porosity
c. Increased vessel flexibility
d. Enlarged vessel dexterity

33. Regulator of body temperature.

a. Sebaceous glands
b. Hypothalamus
c. Medulla
d. Wernicke’s area

34. Acute pain and anxiety increase pulse rates because of what reason?
a. Sympathetic nerves are stimulated
b. Parasympathetic nerves are suppressed.
c. Sympathetic nerves are suppressed
d. Parasympathetic nerves are stimulated

35. Never measure both carotid pulse at the same time because excessive pressure may cause to occlude blood supply to
the brain.
a. True
b. False
c. Maybe
d. Weh? How?

36. A student nurse taking care of a patient with an abnormal body temperature needs more training when he/she does
what?
a. Further assess for possible site of localized infection
b. Discourages a patient from drinking fluids to avoid excessive activity
c. Cover patient with more blankets, close room, doors, or windows
d. Monitor patient’s temperature at least every 4 hours or PRN

37. When body temperature falls below 93.2 degrees Fahrenheit, the person is suffering from extreme
a. Orthopnea
b. Hypothermia
c. Hyperthermia
d. Dyspnea

38. Considered the 5th vital sign

a. Height and weight
b. Respiration
c. Pain
d. Body mass index

39. Pulse rate faster than 100 beats per minute

a. Tachycardia
b. Orthopnea
c. Tachypnea
d. Bradycardia

40. A proper assessment of the vital signs will allow a nurse to: (SATA)
a. Learn about human behavior
b. Implement planned interventions
c. Help evaluate improvement of patient condition
d. Identify nursing diagnosis

41. In assessing a tympanic temperature in a 20-year-old male patient, which of the following could result in the least
accurate reading?
a. The patient has been outdoor for more than 30 minutes
b. The pinna is pulled backwards and up
 c. A plastic probe covers the tip of the thermometer
d. The lens and the probe of the device are clean and intact

42. Surface and Core

a. Pain
b. Blood pressure
c. Temperature
d. Pulse

43. Factors affecting body temperatures. (SATA)

a. Height
b. Age
c. Smoking
d. Stress
d. Hormones

44. The colored probes of an electronic thermometer are indicative of:

a. Blue is for oral and red is for rectal
b. Blue and red are both for rectal
c. Blue is for rectal and red is for oral
d. Blue and red are both for oral

45. Decreased efficiency of respiratory muscles results in breathlessness at low exercise levels.
a. True
b. False
c. Unknown
d. Maybe.

46. Considered the least accurate method of measuring temperature.

a. Axillary
b. Rectal
c. Tympanic
d. Oral

47. When obtaining an oral temperature, after requesting the patient to open the mouth, the probe is gently inserted into:
a. Superior lingual mucosity
b. Lateral sublingual density
c. Anterior sublingual cavity
d. Posterior sublingual pocket

48. This condition may produce a subnormal temperature.

a. Infection
b. Fever
c. Hypothyroidism
d. Cerebral palsy

49. A sudden drop in blood pressure because of position changes is called ___________________
___________________ (two words).

50. Resting in supine position could cause to decrease the heart rate. What cardiac condition does the same thing?
_________ _________ (two words).

PART II. MATCHING TYPE. Write the letter of your answer on the space provided for.

Match the type of pulse volume variations with their descriptions.

______51. Absent Pulse
______52. Thready Pulse
______53. Weak Pulse
______54. Normal Pulse
______55. Bounding Pulse

A. Easily felt but not palpable when moderate pressure applied

B. Feels full and springlike even under moderate pressure
C. Difficult to feel, not palpable when only slight pressure applied
D. None felt
E. Somewhat stronger than a thread pulse but not palpable when light pressure applied.

Match the numbers of the pulse volume variations on the left with the types on the right.
_____56. 0 A. Normal Pulse
_____57. 1+ B. Weak Pulse
_____58. 2+ C. Absent Pulse
_____59. 3+ D. Bounding Pulse
_____60. 4+ E. Thready Pulse

Match the normal range of respiratory rate on the left with the correct age group on the right.
_____61. 36-60 A. Toddler
_____62. 40-46 B. Adult
_____63. 20-30 C. Infant
_____64. 22-24 D. School age (6-10yrs)
_____65. 16-22 E. Older Adult
_____66. 12-20 F. Adolescent (10-18yrs)
_____67. 12-18 G. Neonate

Match the site with the corresponding normal body temperatures (in Fahrenheit)
_____68. Oral and Tympanic A. 99.5
_____69. Rectal B. 97.6
_____70. Axillary C. 98.6

Match the sites for temperature readings with its advantages.

_____71. Oral
_____72. Rectal
_____73. Axilla
_____74. Tympanic
_____75. Temporal artery

A. Tolerated well by most children

B. Non-invasive but provides core reading
C. Considered safe but not very accurate
D. More reliable when oral temperature cannot be obtained
E. Most accessible site, comfortable for patients, no need for position changes.

Match the heart rate range on the left with the age group on the right.
_____76. 120-160 bpm A. Infant
_____77. 60-100 bpm B. Neonate
_____78. 125-135 bpm C. School age
_____79. 65-105 bpm D. Older adult
BONUS 80.