Question 1

The nurse assesses the blood pressure to be 140/62 mm Hg and records 78 as the:

Accepted Answer

A)  pulse pressure. 
B)  pulse deficit. 
C)  afterload. 
D)  preload. 
A)  pulse pressure. 
B)  pulse deficit. 
C)  afterload. 
D)  preload. A

Question 2

During respiration, the internal intercostals:

Accepted Answer

A)  increase the force of muscular contraction. 
B)  decrease the lateral diameter during expiration. 
C)  decrease the intrathoracic space. 
D)  increase elastic recoil during expiration. 
A)  increase the force of muscular contraction. 
B)  decrease the lateral diameter during expiration. 
C)  decrease the intrathoracic space. 
D)  increase elastic recoil during expiration. B

Question 3

Postural hypotension is defined as a ___________________ when the patient stands compared with sitting or supine readings.

Accepted Answer

A)  systolic pressure drop of more than 15 mm Hg with a pulse rate increase 
B)  pulse rate decrease with a systolic pressure increase of at least 15 mm Hg 
C)  diastolic pressure increase of more than 5 mm Hg and no pulse rate changes 
D)  pulse rate decrease and diastolic pressure decrease of more than 5 mm Hg 
A)  systolic pressure drop of more than 15 mm Hg with a pulse rate increase 
B)  pulse rate decrease with a systolic pressure increase of at least 15 mm Hg 
C)  diastolic pressure increase of more than 5 mm Hg and no pulse rate changes 
D)  pulse rate decrease and diastolic pressure decrease of more than 5 mm Hg A

Question 4

The most frequent cause of serious hypertension in children is:

Accepted Answer

A)  heart disease. 
B)  liver failure. 
C)  renal disease. 
D)  rheumatic fever. 
A)  heart disease. 
B)  liver failure. 
C)  renal disease. 
D)  rheumatic fever.

Question 5

The Joint Commission (TJC) requires that:

Accepted Answer

A)  pain be assessed on all discharges. 
B)  repeated assessment of pain be limited to those patients who complain of pain. 
C)  repeated intensity documentation be made of the course of pain relief for all patients. 
D)  pain be assessed on surgical patients. 
A)  pain be assessed on all discharges. 
B)  repeated assessment of pain be limited to those patients who complain of pain. 
C)  repeated intensity documentation be made of the course of pain relief for all patients. 
D)  pain be assessed on surgical patients.

Question 6

Which of the following occurs with malignant hypertension?

Accepted Answer

A)  Blurred vision 
B)  Sleep disturbance 
C)  Tachycardia 
D)  Dyspnea 
E)  Encephalopathy 
A)  Blurred vision 
B)  Sleep disturbance 
C)  Tachycardia 
D)  Dyspnea 
E)  Encephalopathy

Question 7

Underestimation of blood pressure will occur if the cuff's width covers:

Accepted Answer

A)  less than half of the upper arm. 
B)  less than 5 inches of the lower arm. 
C)  more than two thirds of the upper arm. 
D)  more than 4 inches of the lower arm. 
A)  less than half of the upper arm. 
B)  less than 5 inches of the lower arm. 
C)  more than two thirds of the upper arm. 
D)  more than 4 inches of the lower arm.

Question 8

Body language that leads you to suspect that a person is in pain is:

Accepted Answer

A)  talkative, verbose speech. 
B)  fretful hand movements. 
C)  focused, fixed eye stares. 
D)  marked salivation. 
A)  talkative, verbose speech. 
B)  fretful hand movements. 
C)  focused, fixed eye stares. 
D)  marked salivation.

Question 9

Ms. Green is an 85-year-old female patient with dementia who presents to the emergency department with her daughter because of a change in function. Which pain assessment scale would be the best choice?

Accepted Answer

A)  Oucher Scale 
B)  Checklist for Nonverbal Pain Indicators 
C)  Wong/Baker Rating Scale 
D)  CRIES Scale 
A)  Oucher Scale 
B)  Checklist for Nonverbal Pain Indicators 
C)  Wong/Baker Rating Scale 
D)  CRIES Scale

Question 10

In a syndrome in which regional pain extends beyond this specific peripheral nerve injury, you would notice which of the following:

Accepted Answer

A)  Allodynia 
B)  Sleep disturbance 
C)  Blood flow changes 
D)  Numbness 
E)  Edema 
A)  Allodynia 
B)  Sleep disturbance 
C)  Blood flow changes 
D)  Numbness 
E)  Edema

Question 11

The pyrexia response is triggered by the production and release of:

Accepted Answer

A)  prostaglandins. 
B)  endogenous pyrogens. 
C)  hypothalamic enzymes. 
D)  thyroid hormones. 
A)  prostaglandins. 
B)  endogenous pyrogens. 
C)  hypothalamic enzymes. 
D)  thyroid hormones.

Question 12

A blood pressure cuff bladder should be long enough to:

Accepted Answer

A)  cover 20% to 25% of the arm circumference. 
B)  cover 45% to 50% of the arm circumference. 
C)  cover 75% to 80% of the arm circumference. 
D)  completely encircle the arm. 
A)  cover 20% to 25% of the arm circumference. 
B)  cover 45% to 50% of the arm circumference. 
C)  cover 75% to 80% of the arm circumference. 
D)  completely encircle the arm.

Question 13

The perception of pain:

Accepted Answer

A)  is the same across cultures. 
B)  can be easily assessed in neonates. 
C)  is predictable with the same circumstances. 
D)  is affected by emotions and quality of sleep. 
A)  is the same across cultures. 
B)  can be easily assessed in neonates. 
C)  is predictable with the same circumstances. 
D)  is affected by emotions and quality of sleep.

Question 14

Hypertension in the adult is generally defined as pressure in excess of:

Accepted Answer

A)  120 mm Hg plus the patient's age. 
B)  140 mm Hg. 
C)  160 mm Hg. 
D)  200 mm Hg. 
A)  120 mm Hg plus the patient's age. 
B)  140 mm Hg. 
C)  160 mm Hg. 
D)  200 mm Hg.

Question 15

Pain is often referred to as the fifth vital sign because ____________________.

Accepted Answer

of its ass

Question 16

The difference in blood pressure readings between the right and the left arms is considered normal up to ___ mm Hg.

Accepted Answer

Blood pressure readings betwee

Question 17

If only two blood pressure values are recorded, they are the _______________ sounds.

Accepted Answer

Phase 1 (systolic sound) and p

Question 18

If a sufficiently large cuff is unavailable to fit an obese arm, which technique may be used to assess blood pressure?

Accepted Answer

A)  Wrap a standard cuff around the deltoid area and place the stethoscope over the radial artery. 
B)  Wrap a standard cuff around the forearm and place the stethoscope over the radial artery. 
C)  Wrap a standard cuff around the thigh and place the stethoscope on the dorsalis pedis. 
D)  Wrap a pediatric cuff around the ankle and place the stethoscope on the popliteal artery. 
A)  Wrap a standard cuff around the deltoid area and place the stethoscope over the radial artery. 
B)  Wrap a standard cuff around the forearm and place the stethoscope over the radial artery. 
C)  Wrap a standard cuff around the thigh and place the stethoscope on the dorsalis pedis. 
D)  Wrap a pediatric cuff around the ankle and place the stethoscope on the popliteal artery.

Question 19

You are completing an examination on a 4-year-old child. Pain scales that are reliable and valid for children are the _____ Scales.

Accepted Answer

The Wong/Baker Faces Rating an

Question 20

The fifth vital sign is:

Accepted Answer

A)  pain. 
B)  orientation. 
C)  waist-to-hip ratio. 
D)  body mass index (BMI). 
A)  pain. 
B)  orientation. 
C)  waist-to-hip ratio. 
D)  body mass index (BMI).

Exam 4: Vital Signs and Pain Assessment

The nurse assesses the blood pressure to be 140/62 mm Hg and records 78 as the:

During respiration, the internal intercostals:

Postural hypotension is defined as a ___________________ when the patient stands compared with sitting or supine readings.

The most frequent cause of serious hypertension in children is:

The Joint Commission (TJC) requires that:

Which of the following occurs with malignant hypertension?

Underestimation of blood pressure will occur if the cuff's width covers:

Body language that leads you to suspect that a person is in pain is:

Ms. Green is an 85-year-old female patient with dementia who presents to the emergency department with her daughter because of a change in function. Which pain assessment scale would be the best choice?

In a syndrome in which regional pain extends beyond this specific peripheral nerve injury, you would notice which of the following:

The pyrexia response is triggered by the production and release of:

A blood pressure cuff bladder should be long enough to:

The perception of pain:

Hypertension in the adult is generally defined as pressure in excess of:

Pain is often referred to as the fifth vital sign because ____________________.

The difference in blood pressure readings between the right and the left arms is considered normal up to ___ mm Hg.

If only two blood pressure values are recorded, they are the _______________ sounds.

If a sufficiently large cuff is unavailable to fit an obese arm, which technique may be used to assess blood pressure?

You are completing an examination on a 4-year-old child. Pain scales that are reliable and valid for children are the _____ Scales.

The fifth vital sign is:

The History and Interviewing Process

Cultural Competency

Examination Techniques and Equipment

Mental Status

Growth and Measurement

Nutrition

Skin, Hair, and Nails

Lymphatic System

Head and Neck

Eyes

Ears, Nose, and Throat

Chest and Lungs

Heart

Blood Vessels

Breasts and Axillae

Abdomen

Female Genitalia

Male Genitalia

Anus, Rectum, and Prostate

Musculoskeletal System

Neurologic System

Sports Participation Evaluation

Putting It All Together

Taking the Next Steps: Critical Thinking

Recording Information

Emergency or Life-Threatening Situations

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