CHAPTER 7 BASED QUESTIONS AND
ANSWERS
The nurse is applying the blood pressure cuff on a client's arm. Which action would be most
appropriate?
The cuff starts to be wrapped at the end of the bladder.
The cuff is placed about 1 inch above the antecubital area.
The bladder inside the cuff encircles 50% of the arm circumference.
The cuff is wrapped loosely around the arm. - ANS-✅The cuff is placed about 1 inch above the
antecubital area.
A nurse observes the posture of a male client and finds him leaning forward and bracing himself while
sitting on the exam table. Which of the following would the nurse most likely suspect?
Balance disorder
Neurological deficit
Metabolic disorder
Chronic obstructive pulmonary disease - ANS-✅Chronic obstructive pulmonary disease
The nurse is reviewing the following vital signs of a client who is lying in bed. Which of the following
would the nurse identify as being abnormal?
Oral temperature 36.6
Blood pressure 116/68 mm Hg
Respirations 28 breaths/minute
Radial pulse 78 beats/minute - ANS-✅Respirations 28 breaths/minute
After describing the pathophysiology of pain, an instructor determines that the students have
understood the teaching when they identify which of the following as being responsible for transmitting
the sensations to the central nervous system?
Nociceptors
Cytokines
Transduction
Modulation - ANS-✅Nociceptors
A client presents to the ED with pain in the upper right quadrant that worsens after eating. The client
describes the pain as sharp, stabbing, and at times very intense. This is a description of which type of
pain?
Phantom
Cutaneous
Chronic
Acute - ANS-✅Acute
A nurse has an order to obtain orthostatic blood pressure readings on a client admitted with
dehydration. The sitting blood pressure is 140/75mmHg. Which blood pressure reading with the client
standing should the nurse recognize as orthostatic hypotension?
, 140/55 mmHg
160/85 mmHg
120/55 mmHg
130/65 mmHg - ANS-✅120/55 mmHg
A client presents to the health care clinic with reports of two-day history of sore throat pain, ear
pressure, fever, and stiff neck. The client states they have taken Tylenol and lozenges without relief.
Which nursing diagnosis can be confirmed by this data?
Risk for Fluid Volume Deficit related to fever
Impaired Mobility related stiff neck
Anxiety related to prolonged pain
Acute Pain related to sore throat - ANS-✅Acute Pain related to sore throat
The nurse is assessing a client's pain. Which of the following would lead the nurse to suspect that the
client is experiencing pain?
Sitting upright, hands on lap
Facial grimacing, leaning forward
Regular, unlabored breathing
Alert, talkative demeanor - ANS-✅Facial grimacing, leaning forward
A nurse documents periods of deep breathing followed by periods of apnea. The appropriate term for
this type of breathing is
hypopnea
ataxic
obstructive
Cheyne-Stokes - ANS-✅Cheyne-Stokes
The nurse is caring for a post-operative client with an order for morphine sulfate 2 mg IV push every 4
hours. The client's pain is unrelieved 30 minutes following administration of the morphine sulfate with
the pain rating increasing from 7 to 10. Which action should the nurse take?
Wait and medicate the client when the next dose of morphine is due.
Call the prescribing physician see about changing the pain medication.
Instruct the client that it is too soon for another dose of morphine.
Administer another dose of the morphine sulfate immediately. - ANS-✅Call the prescribing physician
see about changing the pain medication.
A nurse is assessing the blood pressure on an obese woman. What error might occur if the cuff used is
too narrow?
Pressure on the cuff would be painful.
Reading is erroneously high.
Reading is erroneously low.
It will be difficult to pump up the bladder. - ANS-✅Reading is erroneously high.
A 55-year-old bookkeeper comes to the office for a routine visit. The nurse notes that on a previous visit
for treatment of contact dermatitis, the client's blood pressure was elevated. She does not have prior
elevated readings, and her family history is negative for hypertension. The nurse measures her blood
pressure in the office today. Which of the following factors can result in a false high reading?
Client is seated quietly for 10 minutes prior to measurement.
Blood pressure is measured on a bare arm.