Vital Signs Assessment in Nursing (NUR
155/156) UPDATED ACTUAL Questions
and CORRECT Answers
Vital signs - CORRECT ANSWER - Used to monitor the functioning of body systems.
Assessment of vital signs - CORRECT ANSWER - Allows the nurse to detect changes in the
health status of the patient, identify early warning signs of life-threatening health conditions, and evaluate
the effectiveness of interventions.
Vital signs consist of - CORRECT ANSWER - Body temperature, pulse, respirations, and blood
pressure.
Factors affecting body temperature - CORRECT ANSWER - Age, recent exercise, hormone
fluctuations, circadian rhythms, stress, environment, and smoking.
Hypothermia - CORRECT ANSWER - A condition where body temperature is abnormally low.
Hyperthermia - CORRECT ANSWER - A condition where body temperature is abnormally high.
Fever - CORRECT ANSWER - An elevated body temperature often due to infection.
Heatstroke - CORRECT ANSWER - A severe heat illness that occurs when the body temperature
rises to dangerous levels.
Heat exhaustion - CORRECT ANSWER - A heat-related illness that can occur after prolonged
exposure to high temperatures.
Assessment of temperature - CORRECT ANSWER - Involves using the correct equipment and
procedure at the most appropriate site.
, Sites for temperature measurement - CORRECT ANSWER - Mouth, ear, rectum, forehead, and
axilla.
Types of thermometers - CORRECT ANSWER - Electronic thermometers, disposable
thermometers, and noncontact infrared thermometers.
Signs and Symptoms of Fever - CORRECT ANSWER - Anorexia, headache, malaise, hot dry
skin, flushing, thirst, shivering, general feeling of not being well.
Nursing diagnosis: Hyperthermia - CORRECT ANSWER - Supporting Data: Infectious process,
temperature of 38.89° C (102° F).
Nursing diagnosis: Hypothermia - CORRECT ANSWER - Supporting Data: Exposure to below-
freezing temperature without adequate clothing, temperature of 93.6° F.
Nursing diagnosis: Impaired Thermoregulation - CORRECT ANSWER - Supporting Data:
Premature infant of 32 weeks' gestation, inability to maintain temperature within normal range.
Apical Pulse - CORRECT ANSWER - Palpate for Apical Pulse at the PMI at fifth intercostal
space, left midclavicular line.
Pulse assessment - CORRECT ANSWER - Includes pulse rate, rhythm, intensity, and presence of
dysrhythmia/arrhythmia.
Nursing diagnosis: Impaired Peripheral Tissue Perfusion - CORRECT ANSWER - Supporting
data: Decreased peripheral circulation, pedal edema, the need to use doppler ultrasound to detect pedal
pulses.
Nursing diagnosis: Activity Intolerance - CORRECT ANSWER - Supporting Data: Immobility,
shortness of breath with ambulation, increased pulse rate with activity.
Nursing diagnosis: Impaired Cardiac Output - CORRECT ANSWER - Supporting Data: Altered
contractility of the heart, shortness of breath, peripheral edema, tachycardia.
155/156) UPDATED ACTUAL Questions
and CORRECT Answers
Vital signs - CORRECT ANSWER - Used to monitor the functioning of body systems.
Assessment of vital signs - CORRECT ANSWER - Allows the nurse to detect changes in the
health status of the patient, identify early warning signs of life-threatening health conditions, and evaluate
the effectiveness of interventions.
Vital signs consist of - CORRECT ANSWER - Body temperature, pulse, respirations, and blood
pressure.
Factors affecting body temperature - CORRECT ANSWER - Age, recent exercise, hormone
fluctuations, circadian rhythms, stress, environment, and smoking.
Hypothermia - CORRECT ANSWER - A condition where body temperature is abnormally low.
Hyperthermia - CORRECT ANSWER - A condition where body temperature is abnormally high.
Fever - CORRECT ANSWER - An elevated body temperature often due to infection.
Heatstroke - CORRECT ANSWER - A severe heat illness that occurs when the body temperature
rises to dangerous levels.
Heat exhaustion - CORRECT ANSWER - A heat-related illness that can occur after prolonged
exposure to high temperatures.
Assessment of temperature - CORRECT ANSWER - Involves using the correct equipment and
procedure at the most appropriate site.
, Sites for temperature measurement - CORRECT ANSWER - Mouth, ear, rectum, forehead, and
axilla.
Types of thermometers - CORRECT ANSWER - Electronic thermometers, disposable
thermometers, and noncontact infrared thermometers.
Signs and Symptoms of Fever - CORRECT ANSWER - Anorexia, headache, malaise, hot dry
skin, flushing, thirst, shivering, general feeling of not being well.
Nursing diagnosis: Hyperthermia - CORRECT ANSWER - Supporting Data: Infectious process,
temperature of 38.89° C (102° F).
Nursing diagnosis: Hypothermia - CORRECT ANSWER - Supporting Data: Exposure to below-
freezing temperature without adequate clothing, temperature of 93.6° F.
Nursing diagnosis: Impaired Thermoregulation - CORRECT ANSWER - Supporting Data:
Premature infant of 32 weeks' gestation, inability to maintain temperature within normal range.
Apical Pulse - CORRECT ANSWER - Palpate for Apical Pulse at the PMI at fifth intercostal
space, left midclavicular line.
Pulse assessment - CORRECT ANSWER - Includes pulse rate, rhythm, intensity, and presence of
dysrhythmia/arrhythmia.
Nursing diagnosis: Impaired Peripheral Tissue Perfusion - CORRECT ANSWER - Supporting
data: Decreased peripheral circulation, pedal edema, the need to use doppler ultrasound to detect pedal
pulses.
Nursing diagnosis: Activity Intolerance - CORRECT ANSWER - Supporting Data: Immobility,
shortness of breath with ambulation, increased pulse rate with activity.
Nursing diagnosis: Impaired Cardiac Output - CORRECT ANSWER - Supporting Data: Altered
contractility of the heart, shortness of breath, peripheral edema, tachycardia.
