BASIC NURSING ESSENTIALS FOR PRACTICE 7TH EDITION BY POTTER - TEST BANK

Potter: Basic Nursing, 7th Edition Chapter 03: Community-Based Nursing Practice Test Bank MULTIPLE CHOICE 1. A student nurse is beginning her community health rotation. She anticipates that her assignment in community-based health care will most likely be at which of the following organizations? A. Acute care hospital B. Rehabilitation hospital C. Nursing home D. High school ANS: D High schools focus on primary rather than acute care and provide knowledge about health and health promotion that occurs outside traditional health care institutions, such as hospitals and nursing homes. PTS: 1 DIF: Cognitive Level: Application REF: 40 OBJ: Discuss the role of the nurse in community-based practice TOP: Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 2. What is the primary characteristic of a community health nurse? A. Providing care to subpopulations B. Providing care in existing services C. Being a specialist in public health science D. Having a case management certification ANS: A Community health nursing incorporates knowledge from published health sciences. It is broader than the focus of public health. A community-based nurse works in an established program that provides health services to specific populations in the community. PTS: 1 DIF: Cognitive Level: Knowledge REF: 39 OBJ: Differentiate community health nursing from community-based nursing TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 3. Which of the following is considered the overall goal of Healthy People 2010? A. To increase the life expectancy of people in the United States B. To increase the health status of people throughout the world C. To eradicate HIV/AIDS D. To reduce health care costs ANS: A The overall goals of Healthy People 2010 are to increase the life expectancy and quality of life and to eliminate health disparities through an improved delivery of health care services to people in the United States. PTS: 1 DIF: Cognitive Level: Comprehension REF: 37 OBJ: Discuss the role of the nurse in community-based practice TOP: Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 4. The teen pregnancy rate in one community significantly increased, and, as a result, the school system was seeing an increase in the drop-out rate of teenage mothers. A student nurse recently worked with the local school system to develop a day care program for the children of high school students so that they could return to school. This is an example of which of the following? A. Building a relationship with pregnant teens B. Responding to changes within the community C. Influencing community environmental factors D. Managing disease ANS: B Successful community health nursing practice involves building relationships with the community and responding to changes within the community. PTS: 1 DIF: Cognitive Level: Analysis REF: 44 OBJ: Describe selected competencies important for success in community-based nursing practice TOP: Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 5. The most cost-effective health care is which of the following? A. Acute care hospital B. Rehabilitation hospital C. Community-based nursing center D. Physician office ANS: C Community-based nursing centers are the first level of contact between members of a community and the health care delivery system. Ideally, a nurse provides care close to the patient’s residence. This approach helps to reduce the cost of care and to improve access to health care services. PTS: 1 DIF: Cognitive Level: Application REF: 40 OBJ: Discuss the role of the nurse in community-based practice TOP: Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 6. A 56-year-old immigrant from the Czech Republic has diabetes and hypertension. She lives with her daughter whose job requires her to travel. The patient speaks English very well. The community health nurse knows that she may be a vulnerable patient because of which of the following? A. Her age B. Her immigration status C. Her diabetes D. Her hypertension ANS: B Frequently, vulnerable patients come from varied cultures, have different beliefs and values, face language barriers, and have few sources of social support. PTS: 1 DIF: Cognitive Level: Application REF: 42 OBJ: Explain the characteristics of patients from selected vulnerable populations that influence a nurse’s approach to care TOP: Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 7. The most important competency in community nursing is which of the following? A. Caregiver B. Case manager C. Educator D. Risk manager ANS: A Most important is the caregiving role. In the community setting a nurse manages and cares for the community. Using the nursing process and critical thinking skills, a nurse develops appropriate, individualized nursing care for specific patients and their families. In addition, the nurse individualizes care within the context of the patient’s community to achieve long-term successful health care outcomes. PTS: 1 DIF: Cognitive Level: Application REF: 44 OBJ: Describe selected competencies important for success in community-based nursing practice TOP: Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment SHORT ANSWER 1. Community-based nursing provides services that will improve the health of specific populations; in contrast, public health practice ____________________. ANS: aims at achieving a healthy environment for all individuals to live in The principles of public health practice focus on achieving a healthy environment for all individuals to live in. These principles apply to individuals, families, and the communities in which they live. PTS: 1 DIF: Cognitive Level: Comprehension REF: 38 OBJ: Explain the relationship between public health and community health nursing TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance MULTIPLE RESPONSE 1. A nurse in community-based practice needs a variety of skills and talents while rendering care to patients in the community, which includes which of the following? Select all that apply. A. Case manager B. Care giver C. Educator D. Advocate E. Counselor ANS: A, B, C Selected competencies, such as caregiver, case manager, and educator, are used in the community-based setting. PTS: 1 DIF: Cognitive Level: Comprehension REF: 44 OBJ: Describe the competencies important for success in community-based practice TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 2. Vulnerable populations of patients are those who are more likely to develop health problems as a result of which of the following? Select all that apply. A. Living at home B. Abusive habits C. Immigration D. Middle age ANS: B, C Individuals living in poverty, older adults, homeless persons, individuals in abusive relationships, people who abuse chemical substances, people with mental illnesses, and new immigrants are examples of vulnerable populations. PTS: 1 DIF: Cognitive Level: Comprehension REF: 41-42 OBJ: Explain the characteristics of patients from selected vulnerable populations that influence a nurse’s approach to care TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 3. A community assessment involves components to identify needs for health policy, health program development, and services, which include assessing which of the following? Select all that apply. A. Structure B. People C. Social systems D. Environment ANS: A, B, C A complete assessment examines structure or locale, people, and social systems. The principles of public health practice aim at achieving a healthy environment for all individuals to live in. PTS: 1 DIF: Cognitive Level: Analysis REF: 44 OBJ: Describe elements of a community assessment TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance Potter: Basic Nursing, 7th Edition Chapter 07: Critical Thinking Test Bank MULTIPLE CHOICE 1. A registered nurse is caring for a 68-year-old patient in the trauma unit who had been involved in a motor vehicle accident. Although the patient denied pain, during the nurse’s assessment, she observed that he groaned when moving and was protective of his right arm. She believed the patient had pain and reported it to the health care provider who ordered a radiograph of his right arm. The radiograph revealed a fractured humerus. This is best described as which of the following? A. Intuition B. Critical thinking C. Nursing process D. Reflection ANS: B Critical thinking is the active, organized, cognitive process used to carefully examine one’s thinking and the thinking of others. It involves recognizing that an issue (e.g., patient problem) exists, analyzing information related to the issue (e.g., clinical data about a patient), evaluating information (including assumptions and evidence), and drawing conclusions. PTS: 1 DIF: Cognitive Level: Analysis REF: 92 OBJ: Discuss critical thinking skills used in nursing practice TOP: Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 2. A registered nurse is caring for a postoperative patient whose systolic blood pressure has dropped 10 points during his shift. He remembers that this was similar to a situation that happened in the past when the patient developed an internal bleed. The nurse’s thoughts are best described as which of the following? A. Intuition B. Critical thinking C. Nursing process D. Reflection ANS: D Reflection is a part of critical thinking that involves the process of purposefully thinking about or recalling a situation to discover its purpose or meaning. PTS: 1 DIF: Cognitive Level: Analysis REF: 90 OBJ: Discuss critical thinking skills used in nursing practice TOP: Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 3. Blair, a student nurse, is assisting a nurse with admitting a 73-year-old woman with a fractured ulna and radius to the trauma unit of the hospital. The patient’s daughter and son-in-law are with her. Blair notices that the patient does not make eye contact when answering questions and she feels that something is not right about the situation. This can best be explained by which of the following? A. Intuition B. Critical thinking C. Nursing process D. Reflection ANS: A Intuition is the inner sensing or “gut feeling” that something is so. For example, a nurse walks into a patient’s room and, by looking at the patient’s appearance without the benefit of a thorough assessment, senses that he or she has worsened physically. Intuition is a common experience that many people have when interacting with their environments. PTS: 1 DIF: Cognitive Level: Application REF: 91-92 OBJ: Discuss critical thinking skills used in nursing practice TOP: Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 4. A student nurse is with a medical unit during this clinical rotation. She is administering an enema with her instructor in the room. The patient states that they can no longer hold the enema solution. The student nurse acknowledges the patient’s request and begins to tell the patient that he can go to the bathroom to expel the enema. The instructor suggests that the patient wait a few minutes to give the enema solution time to be absorbed into the bowel. In this situation the student nurse demonstrates what level of critical thinking according to Kataoka-Yahiro and Saylor’s model? A. Level 1: Basic B. Level 2: Complex C. Level 3: Commitment D. The student nurse is not demonstrating critical thinking. ANS: A At the basic level of critical thinking a learner trusts that experts have the right answers for every problem. Thinking is concrete and based on a set of rules or principles. PTS: 1 DIF: Cognitive Level: Analysis REF: 92 OBJ: Describe the components of a critical thinking model for clinical decision making TOP: Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 5. A novice nursing student will most likely practice nursing at level _____ of critical thinking according to Kataoka-Yahiro and Saylor's model. A. 1 B. 2 C. 3 D. 4 ANS: A At the basic level of critical thinking a learner trusts that experts have the right answers for every problem. Thinking is concrete and based on a set of rules or principles. PTS: 1 DIF: Cognitive Level: Application REF: 92 OBJ: Describe the components of a critical thinking model for clinical decision making TOP: Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 6. A nursing student learning about the critical thinking process begins with which of the following? A. Collecting data B. Identifying a problem C. Formulating a question D. Evaluating the results ANS: B The steps of the scientific method are as follows: Problem identification; Collection of data; Formulation of a question or hypothesis; Testing the question or hypothesis; Evaluating results of the study. PTS: 1 DIF: Cognitive Level: Application REF: 94 OBJ: Describe the components of a critical thinking model for clinical decision making TOP: Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 7. A registered nurse is explaining to a 35-year-old woman about what she can expect when her peripherally inserted central line is inserted. Which of the following is the best way for the nurse to explain the procedure? A. “A PICC line is about the same as a needle in your arm.” B. “A triluminal catheter will be inserted into your basilic vein.” C. “The PICC line will be threaded through your superior vena cava.” D. “A PICC is a catheter that will be inserted in a vein in your arm.” ANS: D Critical thinkers use language precisely and clearly. When language is unclear and inaccurate, it reflects sloppy thinking. It is important to communicate clearly with patients, their families, and health care professionals. When you use incorrect terminology, jargon or terminology with which a patient is unfamiliar, or vague descriptions, communication is ineffective. PTS: 1 DIF: Cognitive Level: Analysis REF: 91 OBJ: Describe the components of a critical thinking model for clinical decision making TOP: Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 8. A 56-year-old patient receiving blood after an abdominal surgery notified the nurse that her IV pump was alarming. The nurse checked the pump and determined that the tubing was kinked. The tubing was straightened out and the nurse left the room. Five minutes later the IV pump again alarmed. The nurse returned to find the tubing was again kinked. On further investigation, the nurse discovered that the IV tubing had become twisted. This is an example of which of the following on the part of the nurse? A. Effective problem solving B. Diagnostic reasoning C. Scientific method D. Commitment level of critical thinking ANS: A Effective problem solving involves evaluating the solution over time to be sure that it is still effective. PTS: 1 DIF: Cognitive Level: Analysis REF: 94 OBJ: Describe the components of a critical thinking model for clinical decision making TOP: Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 9. A 16-year-old patient on a pediatric unit who underwent an appendectomy for a ruptured appendix 3 days ago complains of acute pain and has a high fever. The nurse is concerned that she may have an infection and notifies the health care provider of the change in her condition. This concern is based on the nurse’s experience as a pediatric nurse. Her ability to make a tentative conclusion regarding this patient’s situation based on observed data is known as what? A. Scientific method B. Clinical inference C. Effective problem solving D. Data collection ANS: B Clinical inference is a critical thinking skill in which a nurse makes tentative conclusions based on observed data or cues existing in patient situations. PTS: 1 DIF: Cognitive Level: Analysis REF: 95 OBJ: Describe the components of a critical thinking model for clinical decision making TOP: Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 10. Roger, a 34-year-old patient with cancer, is undergoing outpatient chemotherapy. Nancy, the nurse caring for him at the clinic where he goes for his treatments notes that Roger’s white blood cell count is very low and he has little energy. Roger’s plan of care is based upon the nursing diagnosis Risk for infection. Nancy provides patient teaching in order to reduce Roger’s risk for infection. Nancy is using which skill in this situation? A. Medical diagnosis B. Scientific method C. Diagnostic reasoning D. Data collection ANS: C Diagnostic reasoning involves the use of cognitive thinking, metacognition (thinking about thinking), and assessment skills to structure situations so a nurse can apply knowledge. Expert nurses make diagnostic conclusions in the form of nursing diagnoses. PTS: 1 DIF: Cognitive Level: Analysis REF: 95 OBJ: Describe the components of a critical thinking model for clinical decision making TOP: Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 11. Stacie, a nursing student, is caring for Mrs. Thames, an elderly lady who recently experienced a stroke. Stacie notices that Mrs. Thames coughs after she eats or drinks. Stacie knew that Mrs. Thames was at risk for aspiration because of the stroke that she had experienced and was concerned that Mrs. Thames may have impaired swallowing. Stacie develops a care plan for Mrs. Thames based on the nursing diagnosis Impaired swallowing. Which of the following is Stacie using to make this nursing diagnosis? A. Medical diagnosis B. Scientific method C. Diagnostic reasoning D. Data collection ANS: C In nursing, diagnostic reasoning is a process of using gathered data, forming inferences, and then logically explaining a clinical judgment. PTS: 1 DIF: Cognitive Level: Analysis REF: 95 OBJ: Explain the relationship between clinical experience and critical thinking TOP: Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 12. A nurse who is demonstrating clinical decision-making is: A. collecting information about a patient and coming to a conclusion about his or her health problems. B. clarifying the problem and analyze possible causes. C. developing a new idea based on experience and knowledge over time. D. selecting appropriate treatment after forming a nursing diagnosis. ANS: D Clinical decision-making is a problem-solving activity that focuses on selecting appropriate treatment after forming diagnostic conclusions. Clinical decision-making requires careful reasoning so that a nurse chooses the option for the best patient outcome on the basis of the patient’s condition and priority of the problem. PTS: 1 DIF: Cognitive Level: Analysis REF: 95 OBJ: Describe the components of a critical thinking model for clinical decision making TOP: Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 13. A new registered nurse working for a busy unit of an acute care teaching hospital begins her shift with four patients. She needs to prioritize care. Which of the following patients should she attend to first? A. Patient who needs assistance in ambulating the hall B. Patient whose blood pressure suddenly drops and who passes out C. Recovering surgical patient whose family has just arrived D. Patient who was just diagnosed with cancer and is alone ANS: B When a nurse provides care for several patients at one time, he or she will need to use decision-making criteria. These criteria include the clinical conditions of the patients, Maslow’s hierarchy of needs, risks involved in treatment delays, and the patients’ expectations of care to determine what patients have the greatest priorities for care. PTS: 1 DIF: Cognitive Level: Analysis REF: 95 OBJ: Describe the components of a critical thinking model for clinical decision making TOP: Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 14. The critical thinking competency that is unique to nurses is the nursing process. Which of the following includes all steps of the nursing process in the correct order? A. Assessment, diagnosis, planning, implementation, and evaluation B. Diagnosis, assessment, planning, implementation, and evaluation C. Planning, assessment, diagnosis, implementation, and evaluation D. Evaluation, diagnosis, planning, implementation, and assessment ANS: A The nursing process is a systematic process that incorporates diagnostic reasoning and clinical decision-making through five steps: assessment, diagnosis, planning, implementation, and evaluation. PTS: 1 DIF: Cognitive Level: Knowledge REF: 96 OBJ: Discuss the relationship of the nursing process to critical thinking TOP: Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 15. A new nurse is working for a surgical unit. One of the postoperative patients has been experiencing a great deal of pain. She notified the surgeon who wrote an order for pain medication. Upon checking the order, she noticed that the dosage was more than three times the normal range for this medication. She called the surgeon to question the order. This is primarily an example of which of the following critical thinking attitudes? A. Confidence B. Risk-taking C. Fairness D. Thinking independently ANS: D A critical thinker does not accept another person’s ideas without question. When thinking independently, a person challenges the ways in which others think and looks for rational and logical answers to problems. PTS: 1 DIF: Cognitive Level: Analysis REF: 98 OBJ: Discuss the effect attitudes for critical thinking have on clinical decision making TOP: Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 16. A nurse for 6 years has always worked for the oncology unit of a hospital. Recently, however, there were cutbacks because more patients are being treated on an outpatient basis, so the nurse transferred to an orthopedic unit where he is caring for a patient who underwent an above-the-knee amputation, something for which he has never provided care. He is to do a dressing change for the amputated leg, so he asks another nurse to help him. He is demonstrating which of the following critical thinking attitudes? A. Humility B. Confidence C. Risk-taking D. Fairness ANS: A Critical thinkers admit what they do not know and try to find the knowledge they need to make a proper decision. Humility is recognizing when one needs more information to make a decision. When a nurse is new to a clinical division and unfamiliar with the patients, he or she should ask for an orientation to the area and ask nurses regularly assigned to the area for assistance. Nurses should also read professional journals regularly to keep updated on new approaches to care. PTS: 1 DIF: Cognitive Level: Analysis REF: 99 OBJ: Discuss the effect attitudes for critical thinking have on clinical decision making TOP: Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 17. A student nurse in her last semester of nursing school found that keeping a journal of her experiences helped her to understand why she took a certain action and to evaluate whether there was a better way of approaching the task. She has found that this has helped her to grow into the role of a nurse. Which of the following critical thinking attitudes is she demonstrating? A. Humility B. Confidence C. Risk-taking D. Reflection ANS: D Reflection is an important aspect of critical thinking. Purposeful reflection leads to a deeper understanding of issues and to the development of judgment and skill. One activity that will help a nurse develop into a critical thinker is reflective journaling. PTS: 1 DIF: Cognitive Level: Application REF: 100 OBJ: Discuss how reflection improves a nurse’s clinical practice TOP: Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 18. A new nurse who has just begun working for an oncology unit is frustrated with trying to figure out the relationships between a patient’s problems and appropriate nursing interventions. The best tool that she can use to synthesize data into meaningful information is which of the following? A. Concept map B. Reflective journal C. Plan of care D. Nursing model ANS: A A concept map is a visual representation of patient problems and interventions that shows their relationship to one another. The primary purpose of a concept map is to synthesize relevant data about a patient, including assessment data, nursing diagnoses, health needs, nursing interventions, and evaluation measures. PTS: 1 DIF: Cognitive Level: Application REF: 101 OBJ: Discuss the relationship of the nursing process to critical thinking TOP: Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 19. A nurse walks into a room and finds a patient to be incoherent. As the nurse examines and observes the patient closely, searches for ideas, and considers scientific principles to plan the patient’s care, the nurse is using: A. inferences. B. reflection. C. intuition. D. accountability. ANS: A When reflecting, one thinks about or recalls a situation to discover purpose or meaning. Intuition is an inner sensing or “gut feeling” about something. Accountability refers to being answerable for one’s actions. PTS: 1 DIF: Cognitive Level: Analysis REF: 95 OBJ: Explain the relationship between clinical experience and critical thinking TOP: Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 20. Last night a nurse spent time instructing a patient on how to monitor his pulse while taking digoxin. The next day the nurse asks the patient to recount the details of this skill. The nurse is using: A. reflection. B. evaluation. C. perseverance. D. assessment. ANS: A When a nurse evaluates, he or she is determining if a patient goal has been met. When a nurse perseveres, he or she seeks resources until a successful approach has been found. Assessment involves the act of collecting pertinent patient data. PTS: 1 DIF: Cognitive Level: Analysis REF: 100 OBJ: Discuss how reflection improves a nurse’s clinical practice TOP: Nursing Process: Evaluation MSC: Client Needs: Safe and Effective Care Environment 21. A patient is admitted with dependent edema. As a nurse assesses the patient for the presence of jugular vein distention, the nurse is using the process of: A. evaluation. B. data collection. C. problem identification. D. testing the hypothesis. ANS: B When a nurse evaluates, he or she is determining if a patient goal has been met. Problem identification and testing the hypothesis are two steps used in the scientific process. PTS: 1 DIF: Cognitive Level: Application REF: 94 OBJ: Discuss critical thinking skills used in nursing practice TOP: Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 22. When using critical thinking, nurses need to incorporate their cognitive skills and: A. integrity. B. attitude. C. reflection. D. assessment. ANS: B Integrity refers to the ability to demonstrate honesty and a willingness to admit to mistakes or inconsistencies. When reflecting, one purposefully thinks about or recalls a situation to discover purpose or meaning. Assessment involves the act of collecting pertinent patient data. PTS: 1 DIF: Cognitive Level: Knowledge REF: 97 OBJ: Discuss the effect attitudes for critical thinking have on clinical decision making TOP: Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 23. The use of diagnostic reasoning involves a rigorous approach to clinical practice and demonstrates that critical thinking cannot be done in what way? A. Logically B. Haphazardly C. Independently D. In a vacuum ANS: B Diagnostic reasoning is a process of using gathered data to logically explain a clinical judgment. The information a nurse collects leads to determining the status of a patient‘s condition and to select proper therapies. PTS: 1 DIF: Cognitive Level: Analysis REF: 96 OBJ: Discuss the effect attitudes for critical thinking have on clinical decision making TOP: Nursing Process: Evaluation MSC: Client Needs: Safe and Effective Care Environment 24. The nursing process organizes the approach to delivering nursing care. To provide the best professional care to patients, a nurse needs to incorporate the nursing process and: A. decision-making. B. problem solving. C. intellectual standards. D. critical thinking skills. ANS: D Nurses use decision-making and problem solving on a daily basis. However, critical thinking skills involve a process and set of skills. Critical thinking includes identification, analysis, evaluation, and making conclusions about a problem. PTS: 1 DIF: Cognitive Level: Analysis REF: 93 OBJ: Discuss critical thinking skills used in nursing practice TOP: Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 25. While a nurse is assessing a patient’s chest pain, the patient states, “The pain hurts in the middle of my chest.” The nurse asks, “Can you tell me where the pain is exactly and describe what it feels like?” This scenario most accurately depicts application of: A. knowledge. B. experience. C. critical thinking attitudes. D. critical thinking standards. ANS: D A knowledge base includes information and theory from the basic sciences, behavioral sciences, and nursing. The knowledge base is used to view patient care needs in a holistic manner. Experience is gained when a nurse observes, senses, and talks with patients and then reflects on those experiences. Critical thinking attitudes are guidelines for how to approach a problem or decision-making situation. PTS: 1 DIF: Cognitive Level: Application REF: 93 OBJ: Discuss critical thinking skills used in nursing practice TOP: Nursing Process: Evaluation MSC: Client Needs: Safe and Effective Care Environment SHORT ANSWER 1. Learning how to correctly administer a bed bath adds to a patient’s comfort. Additional factors contribute to the concept of comfort. Tying together these concepts demonstrates ____________________. ANS: basic critical thinking Problem solving involves evaluating the solution over time to ensure it is still effective. Complex critical thinking includes alternative and perhaps conflicting solutions as answers to the problem. Commitment to critical thinking implies that a nurse makes choices without assistance from others. PTS: 1 DIF: Cognitive Level: Application REF: 93 OBJ: Discuss critical thinking skills used in nursing practice TOP: Nursing Process: Evaluation MSC: Client Needs: Safe and Effective Care Environment Potter: Basic Nursing, 7th Edition Chapter 14: Vital Signs Test Bank MULTIPLE CHOICE 1. Lucas is a nursing student who is obtaining Mrs. Elliott’s vital signs. Mrs. Elliott has gone to the clinic seeking help because she is having chest pain. Which of the following vital signs are most important for Lucas to obtain? A. Temperature, pulse, respirations B. Temperature, pulse, respirations, oxygen saturation C. Temperature, pulse, respirations, blood pressure, oxygen saturation D. Temperature, pulse, respirations, blood pressure, oxygen saturation, pain ANS: D The cardinal vital signs are temperature, pulse, respiration, blood pressure, and oxygen saturation. A sixth vital sign, assessment of pain, is a standard of care in health care settings. Frequently pain and discomfort are the signs that lead a patient to seek health care. Therefore assessing a patient’s pain helps a nurse understand the patient’s clinical status and progress. PTS: 1 DIF: Cognitive Level: Analysis REF: 260 OBJ: Accurately assess body temperature, pulse, respiration, oxygen saturation, and blood pressure TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 2. Upon a patient’s admission to the nursing unit, the registered nurse delegated to the nursing assistive personnel to take her vital signs. What is the registered nurse’s responsibility regarding delegating this task? A. This is inappropriate delegation, the nurse should always take the vital signs. B. The nurse should ask the nursing assistive personnel to report any abnormalities in the measurements. C. The nurse should review and interpret the vital sign measurements. D. This task has been delegated so the nurse is not responsible. ANS: C When caring for a patient, the nurse is responsible for vital sign measurement. A nurse may delegate the measurement of selected vital signs (e.g., stable patients) to nursing assistive personnel. However, it is the nurse’s responsibility to review vital sign measurements, interpret their significance, and make decisions about interventions. PTS: 1 DIF: Cognitive Level: Analysis REF: 260 OBJ: Correctly delegate vital sign measurement to nursing assistive personnel TOP: Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 3. A 36-year-old African American patient has been admitted to the hospital with diabetic ketoacidosis. The nurse who is admitting him notes that his blood pressure is 164/98. Which of the following should the nurse do next? A. Call the physician to report the blood pressure. B. Retake the blood pressure with an electronic device. C. Ask the patient what his blood pressure normally measures. D. Do nothing; this is within a normal range. ANS: C Know the patient’s usual range of vital signs. A patient’s usual values sometimes differ from the standard range for that age or physical state. Use the patient’s usual values as a baseline for comparison with findings taken later. PTS: 1 DIF: Cognitive Level: Analysis REF: 260 OBJ: Accurately assess body temperature, pulse, respiration, oxygen saturation, and blood pressure TOP: Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 4. A man has been taken to the emergency department after passing out while repairing the roof on his house. The temperature outside is 96° F and his skin is warm and dry. How should the nurse obtain his temperature? A. Axillae B. Rectal C. Oral D. Temporal ANS: B Sites reflecting core temperature are more reliable indicators of body temperature than sites reflecting surface temperature, such as the armpit or axillae. PTS: 1 DIF: Cognitive Level: Analysis REF: 265 OBJ: Explain variations in techniques used to assess vital signs in an infant, a child, and an adult TOP: Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 5. Nancy is a 6-year-old who was taken into the hospital after having a seizure at home. Nancy’s mother tells the nurse that she has been ill for the past week and has had a fever with nausea and vomiting. Nancy’s mother believes that the seizure was caused by a fever of 99.5° F, which Nancy had during the course of her illness. What is the nurse’s best response? A. “It probably was a febrile seizure; let’s see what the health care provider thinks.” B. “Has Nancy ever had a seizure in the past?” C. “Febrile seizures are common in children Nancy’s age.” D. “Has Nancy been exposed to anyone with the flu?” ANS: B Dehydration and febrile seizures occur during rising temperatures of children between 6 months and 3 years of age. Febrile seizures are unusual in children older than 5 years of age. PTS: 1 DIF: Cognitive Level: Analysis REF: 262 OBJ: Discuss physiological changes associated with fever TOP: Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 6. Gwen, a nursing assistive personnel, has told Jane, a registered nurse, that Mrs. Roger’s temperature has reached 103.4° F. Mrs. Roger is a patient who was admitted earlier in the shift with a fever of unknown origin. Jane asks Gwen to help her gather the equipment to draw a blood culture on Mrs. Roger. What is the best reason for Jane to draw a blood culture before giving an antipyretic medication? A. The causative organism is most prevalent during a spike in temperature. B. An antipyretic could cause Mrs. Roger’s stomach to become upset. C. An antipyretic will kill the causative organism. D. The antipyretic may interfere with blood clotting. ANS: A Obtain blood specimens at the same time as a temperature spike when the causative organism is most prevalent. PTS: 1 DIF: Cognitive Level: Analysis REF: 263 OBJ: Discuss physiological changes associated with fever TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 7. A nurse is working on a medical unit in an acute care hospital. One of the patients she is caring for has a fever of 100.3° F. The nurse is not going to administer an antipyretic at this time. Which of the following is the best reason why the patient should not receive an antipyretic at this time? A. A temperature of 100.3° F is within the normal range. B. Antipyretics do not work until the body’s temperature is at least 101° F. C. Antipyretics may make the patient drowsy. D. Mild fevers are an important defense mechanism of the body. ANS: D Fever, or pyrexia, is an important defense mechanism. Therefore most health care providers will not treat an adult’s fever until it is higher than 39° C (102.2° F). Mild temperature elevations enhance the body’s immune system by stimulating white blood cell production. Increased temperature reduces the concentration of iron in the blood plasma, causing the growth of bacteria to slow. Fever also fights viral infections by stimulating interferon, the body’s natural virus-fighting substance. PTS: 1 DIF: Cognitive Level: Analysis REF: 263 OBJ: Discuss physiological changes associated with fever TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 8. A 56-year-old grandmother has been admitted to the hospital with a fever of 103.2° F after caring for her 5-year-old granddaughter who also developed a fever. The health care provider has ordered blood cultures, antibiotics, antipyretics, a clear liquid diet, and a chest radiograph. Which of the orders should the nurse do first? A. Administer antibiotic. B. Administer antipyretic. C. Draw blood cultures. D. Obtain chest radiograph. ANS: C The health care provider will order appropriate antibiotics to be given after obtaining the cultures. Antibiotics destroy bacteria and eliminate the body’s stimulus for fever. PTS: 1 DIF: Cognitive Level: Analysis REF: 263 OBJ: Discuss physiological changes associated with fever TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 9. A 4-year-old child was taken to the after-hours pediatric clinic with a fever and a rash. She had been seen by her pediatrician earlier in the day for a sore throat and had been given a prescription for an antibiotic. Later that evening she developed a fever and a rash on her abdomen. The nurse who assesses the child in the clinic suspected the symptoms are associated with which of the following? A. Common symptoms of strep throat B. An allergic response to the prescribed medication C. An undiagnosed illness D. A food allergy ANS: B Sometimes a fever results from a hypersensitivity response to a medication, especially when the medication is taken for the first time. These fevers are often accompanied by other allergy symptoms such as rash or itching. Treatment involves stopping the medication. PTS: 1 DIF: Cognitive Level: Analysis REF: 263 OBJ: Discuss physiological changes associated with fever TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 10. Jenny, a nursing student working on a medical unit in a pediatric hospital, was caring for Helen, a 5-year-old child who was admitted with meningitis. Helen was admitted to the hospital with a fever of 104.5° F and nuchal rigidity. She responded to antipyretics that were ordered. In addition, Jenny instructed Helen’s mother to help reduce the fever by limiting the number of blankets covering Helen. Jenny recognized that additional teaching was necessary when Helen’s mother made which of the following statements? A. “Helen is more comfortable now that her fever is dropping.” B. “I will call you if Helen feels warm.” C. “Helen’s fever is dropping because she is shivering.” D. “I will replace Helen’s heavy sleeper with lighter-weight pajamas.” ANS: C Shivering is counterproductive because of the heat produced by muscle activity. PTS: 1 DIF: Cognitive Level: Analysis REF: 262 OBJ: Discuss physiological changes associated with fever TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 11. Hal is a 26-year-old man who works in construction. He was helping a friend replace a roof on his backyard shed after work on a hot July afternoon. Hal and his friend had a few beers as they worked on the roof. Hal’s friend took him to the hospital after Hal had severe muscle cramps and became confused. Which of the following should the admitting nurse do first when assessing Hal? A. Draw a specimen to check for blood alcohol level. B. Take Hal’s temperature. C. Ask Hal how long he had been sick. D. Start an intravenous line. ANS: B Prolonged exposure to the sun or high environmental temperatures overwhelms the body’s heat loss mechanisms. Heat also depresses hypothalamic function. These conditions cause heat stroke, a dangerous heat emergency, defined as a body temperature of 40° C (104° F) or higher. Signs and symptoms of heat stroke include giddiness, confusion, delirium, excess thirst, nausea, muscle cramps, visual disturbances, and even incontinence. The most important sign of heat stroke is hot, dry skin. A heat stroke can be fatal. PTS: 1 DIF: Cognitive Level: Analysis REF: 262 OBJ: Discuss physiological changes associated with fever TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 12. A registered nurse is caring for a patient who was admitted to the hospital after being involved in a motor vehicle accident. The patient has undergone two surgeries and now has a health care–acquired infection. Multiple medications were ordered. Which of the following would be least appropriate for the nurse to administer to reduce the fever? A. Acetaminophen B. Corticosteroid C. Ibuprofen D. Indomethacin ANS: B Nonsteroidal drugs such as acetaminophen, salicylates, indomethacin, ibuprofen, and ketorolac reduce fever by increasing heat loss. Health care providers generally order antipyretics if a fever is high than 39° C (102.2° F). Corticosteroids reduce heat production by interfering with the hypothalamic response. These drugs mask signs of infection by suppressing the immune system. Corticosteroids are not used to treat a fever. PTS: 1 DIF: Cognitive Level: Analysis REF: 264 OBJ: Discuss physiological changes associated with fever TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 13. A 15-year-old girl was taken to a small rural hospital by her mother. The family had been camping, and it had become very cold during the night. The mother had difficulty waking her daughter in the morning, and she was shivering uncontrollably. Which of the following interventions should the admitting nurse do first? A. Take a detailed health history. B. Wrap the girl in warm blankets. C. Start an intravenous line. D. Draw blood to check for drug overdose. ANS: B The priority treatment for hypothermia is to prevent a further decrease in body temperature. Removing wet clothes, replacing them with dry ones, and wrapping the patient in blankets are key nursing interventions. PTS: 1 DIF: Cognitive Level: Analysis REF: 264 OBJ: Describe nursing interventions that promote heat loss and heat conservation TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 14. Catherine is a student nurse who volunteers twice a month in an inner city clinic. The young mother of an 8-month-old patient brought her daughter to the clinic after taking the little girl’s temperature rectally and obtaining a reading of 100.4° F. The mother was concerned that her daughter might be ill. Which of the following is the best response from Catherine? A. “Babies usually run lower rather than higher temperatures when ill.” B. “Because the temperature is low-grade, it is probably a viral infection.’ C. “Rectal temperatures are higher than temperatures obtained in other sites.” D. “Because the temperature is low-grade, it is probably a bacterial infection.” ANS: C Depending on the site, temperatures will normally vary between 36.0° C (96.8° F) and 38.0° C (100.4° F). It is generally accepted that rectal temperatures are usually 0.5° C (0.9° F) higher than oral temperatures. PTS: 1 DIF: Cognitive Level: Application REF: 265 OBJ: Discuss physiological changes associated with fever TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 15. A senior nursing student is doing her community clinical rotation. When visiting a young family to whom she has been assigned, the mother of the 3-year-old child states that her daughter does not feel well. The nursing student feels her skin, which is warm. She asks the mother if she has taken her temperature to which the mother replies, “Yes, I used the same thermometer that was my great-grandmother’s; it has been used by my family for years. Her oral temperature was 102.3° F.” The most important patient teaching for the nursing student to perform is to discuss: A. the potential for a febrile seizure with this fever. B. the need to contact the health care provider as soon as possible. C. the dangers of using a mercury thermometer. D. isolating the child from her siblings to prevent the spread of infection. ANS: C The mercury-in-glass thermometer was once the standard device found in the clinical setting but has been eliminated from health care facilities because of the environmental hazards of mercury. However, some patients still use mercury-in-glass thermometers at home. When a nurse finds a mercury-in glass thermometer in the home, the patient should be taught about safer temperature devices and be encouraged to dispose of mercury products at appropriate neighborhood hazardous disposal locations. PTS: 1 DIF: Cognitive Level: Analysis REF: 265-266 OBJ: Explain variations in techniques used to assess vital signs in an infant, a child, and an adult TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 16. Roberta is a nursing student who works for a busy postanesthesia unit in a same day surgery center. A 38-year-old postoperative patient who had just undergone a unilateral oophorectomy began developing problems. The nurse asked Roberta to continue to monitor the vital signs while she contacted the surgeon. The best place for Roberta to monitor the patient’s pulse is which of the following sites? A. Femoral B. Radial C. Carotid D. Brachial ANS: C When a patient’s condition suddenly deteriorates, use the carotid site to quickly find a pulse. PTS: 1 DIF: Cognitive Level: Application REF: 268 OBJ: Explain variations in techniques used to assess vital signs in an infant, a child, and an adult TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 17. A man has been admitted to the hospital with lethargy. He was placed on the telemetry unit and is being continuously monitored. He is due to receive his dose of digoxin. The nurse knows that the medication is to be held if the pulse rate is less than 70 beats per minute. Which of the following is the best site to get his pulse reading? A. Apical B. Brachial C. Carotid D. Off the telemetry monitor ANS: A When a patient takes a medication that affects the heart rate, the apical pulse provides a more accurate assessment of heart rate. PTS: 1 DIF: Cognitive Level: Analysis REF: 268 OBJ: Explain variations in techniques used to assess vital signs in an infant, a child, and an adult TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 18. A new nursing student is learning how to take vital signs. He is having difficulty hearing his patient’s apical pulse with his stethoscope. Which of the following would best maximize the sound quality of what he hears through the stethoscope? A. Positioning the diaphragm very lightly on the area he is listening to B. Placing the stethoscope chestpiece directly on the patient’s skin C. Placing the stethoscope on the patient’s back, directly behind the heart D. Using a stethoscope with the longest tubing that he can find ANS: B Always place the stethoscope directly on the skin because clothing obscures the sound. Position the diaphragm to make a tight seal against the patient’s skin. Exert enough pressure on the diaphragm to leave a temporary red ring on the patient’s skin when the diaphragm is removed. PTS: 1 DIF: Cognitive Level: Application REF: 268 OBJ: Explain variations in techniques used to assess vital signs in an infant, a child, and an adult TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 19. A nursing student is learning to take vital signs. He is practicing taking a pulse at home on his mother. He carefully counts the beats per minute and determines the rhythm. He finds that his mother’s heart rate is 58 beats per minute. He knows that this is considered: A. tachycardia. B. bradycardia. C. a normal heart rate for an adult. D. a dysrhythmia. ANS: B Tachycardia is an abnormally elevated heart rate, more than 100 beats per minute in adults. Bradycardia is a slow rate, less than 60 beats per minute in adults. PTS: 1 DIF: Cognitive Level: Comprehension REF: 270 OBJ: Identify ranges of acceptable vital sign values for an adult, child, and infant TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 20. Michael is a nursing student volunteering at a health screening for hypertension. Mrs. English, a 63-year-old woman who has gone to the clinic, has had her blood pressure taken. Her blood pressure reading was 140/90 mm Hg. Mrs. English is concerned with this reading. Which of the following statements should Michael make to provide Mrs. English with the most accurate information regarding hypertension? A. “You should have your health care provider check your blood pressure again within 2 months.” B. “You have hypertension and should be seen by your health care provider immediately.” C. “Your blood pressure reading is normal for a person your age.” D. “If you don’t seek treatment for your high blood pressure, you could have a stroke.” ANS: A One BP recording revealing a high SBP or DBP does not qualify as a diagnosis of hypertension. However, if a nurse assesses a high reading (e.g., 150/90 mm Hg), the patient should be encouraged to return for another checkup within 2 months. PTS: 1 DIF: Cognitive Level: Analysis REF: 272 OBJ: Describe factors that cause variations in vital signs TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 21. Mrs. Tensley is a 45-year-old mother of three children who recently found out that she has high blood pressure when she was hospitalized for a hysterectomy. Heather, as a student nurse, was caring for Mrs. Tensley during her hospitalization. Mrs. Tensley confided to Heather that she did not want to have to take medication for the high blood pressure. Heather’s best response to Mrs. Tensley is which of the following? A. “Although you need to take your medication, you may be able to lower your blood pressure by maintaining an ideal body weight and reducing stress.” B. “You will always need medication to control your hypertension.” C. “You need to continue to take your medication because you have a family history of hypertension.” D. “You can most likely wean yourself off your medication a little at a time.” ANS: A Persons with a family history of hypertension are at significant risk. Obesity, cigarette smoking, heavy alcohol consumption, high blood cholesterol levels, and continued exposure to stress are also linked to hypertension. PTS: 1 DIF: Cognitive Level: Analysis REF: 271 OBJ: Describe factors that cause variations in vital signs TOP: Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 22. Mrs. Hyatt just returned to the postsurgical unit after undergoing surgery to remove a lung tumor. During one of the postoperative vital sign checks, the student nurse noted that Mrs. Hyatt’s systolic blood pressure had dropped by 10 points within 30 minutes. In addition to the drop in systolic blood pressure, Mrs. Hyatt’s skin was pale. Which of the following should the student nurse do first? A. Report the findings to the nurse. B. Retake the blood pressure with an automatic blood pressure machine. C. Check Mrs. Hyatt’s dressing. D. Nothing; this is a normal occurrence following a thoracic surgery. ANS: A Signs and symptoms associated with hypotension include pallor, skin mottling, clamminess, confusion, dizziness, chest pain, increased heart rate, and decreased urine output. Hypotension is usually life threatening and needs to be reported to a physician immediately. PTS: 1 DIF: Cognitive Level: Analysis REF: 272 OBJ: Describe factors that cause variations in vital signs TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 23. Mr. Johnson is a patient who was admitted to the hospital with chronic obstructive pulmonary disease. He has smoked cigarettes for 33 years and is currently trying to quit his two packs-a-day habit. Upon admission to the hospital, Marsha, a registered nurse is taking his vital signs and is obtaining a pulse oximetry reading. Mr. Johnson asks Marsha what this reading tells her. What is Marsha’s best answer? A. “This tells me what your heart rate is.” B. “This tells me how well your lungs are perfusing.” C. “This is a way for me to measure your respiratory rate.” D. “This reading tells me how deeply you are breathing.” ANS: B Ventilation is assessed by determining respiratory rate, respiratory depth, and respiratory rhythm, and diffusion and perfusion are assessed by determining oxygen saturation. PTS: 1 DIF: Cognitive Level: Analysis REF: 279 OBJ: Describe factors that cause variations in vital signs TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 24. A woman has been hospitalized with pneumonia. She has had oxygen on via nasal cannula at a rate of 2 L per minute. A nursing student is taking her vital signs. She notes that her respirations are labored and the rate is 22 respirations per minute. The nursing student recognizes this as: A. a normal respiratory rate for an adult. B. tachypnea. C. bradypnea. D. apnea. ANS: B A respiratory rate less than 12 per minute or lower than acceptable limits is bradypnea; a rate higher than 20 or greater than the acceptable limits is tachypnea. Apnea is the lack of respiratory movements. PTS: 1 DIF: Cognitive Level: Knowledge REF: 278 OBJ: Identify ranges of acceptable vital sign values for an adult, child, and infant TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 25. A registered nurse is volunteering at a health fair in an African American urban neighborhood. She is working at the blood pressure booth and has noted that many of the clients having blood pressure checks have elevated blood pressure readings. She remembers that this is most likely because: A. African Americans have a higher rate of hypertension than the general population. B. African Americans are under more stress than the general population. C. fewer African Americans take hypertensive medications. D. people in urban settings generally have higher blood pressure readings than people who live in rural areas. ANS: A African Americans tend to develop more severe hypertension at an earlier age and have twice the risk for complications of hypertension such as stroke and heart attack. Hypertension-related deaths are also higher among African Americans. PTS: 1 DIF: Cognitive Level: Analysis REF: 271 OBJ: Describe factors that cause variations in vital signs TOP: Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 26. A patient is obese. The nursing assistant takes the patient’s blood pressure with a standard-size cuff. The nurse educates the assistant by stating that the use of this cuff will affect the reading with values that are: A. accurate. B. indistinct. C. falsely low. D. falsely high. ANS: D An accurate blood pressure (BP) reading will be attained when the BP cuff is 40% of the circumference of the midpoint of the limb. A falsely low BP occurs when the cuff is too wide for the limb. PTS: 1 DIF: Cognitive Level: Application REF: 273 OBJ: Explain variations in techniques used to assess vital signs in an infant, a child, and an adult TOP: Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 27. A nurse delegates the task of obtaining vital signs to a nursing assistant. The nurse reminds the nursing assistant that blood pressure of an infant: A. will be lower than an adult’s. B. is essentially the same as an adult’s. C. is labile during the first months of life. D. is highly sensitive to changes in nursing personnel. ANS: A Blood pressure reflects the interrelationships between cardiac output, peripheral vascular resistance, blood volume, blood viscosity, and arterial elasticity. Blood pressure will continue to rise with advancing age. Blood pressure is sensitive to the size of the cuff and position of the body and arm. PTS: 1 DIF: Cognitive Level: Knowledge REF: 271 OBJ: Correctly delegate vital sign measurement to nursing assistive personnel TOP: Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment 28. A nursing assistant asks the nurse why she needs to bathe a febrile patient. The best response is that this intervention increases heat loss through: A. convection. B. radiation. C. conduction. D. evaporation. ANS: C Convection is the transfer of heat away from the body or an object by air movement. Radiation is the transfer of heat between two objects without physical contact. Evaporation is the transfer of heat energy when a liquid is changed to a gas. PTS: 1 DIF: Cognitive Level: Application REF: 261 OBJ: Discuss physiological changes associated with fever TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 29. A nurse is ready to take the temperature of an adult patient who has just ingested a hot cup of tea. The nurse’s most appropriate action would be to: A. take a rectal temperature. B. take the oral temperature as planned. C. ask the patient to rinse her mouth out with cold water. D. wait 30 minutes and take the oral temperature at that time. ANS: D A rectal temperature is taken when oral route is difficult or impossible to obtain. Oral temperatures are inaccurate when the patient has recently ingested hot or cold fluids. Hot or cold substances will cause false temperature readings. PTS: 1 DIF: Cognitive Level: Analysis REF: 265 OBJ: Explain variations in techniques used to assess vital signs in an infant, a child, and an adult TOP: Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment 30. A nurse notices that a patient has an irregular pulse. To best assess an irregularity in pulses the nurse should: A. determine the rate of the pulse. B. take the apical pulse for one full minute. C. auscultate for the strength of the apical pulse. D. ask if the patient feels a palpation or abnormality of the pulses. ANS: B An irregular heart rate is more accurate when measured for one full minute at the apical site. The apical site produces S1 and S2; the strength of a pulse is felt at peripheral sites. Oftentimes a patient is unaware his or her pulse is abnormal. Always consult the history and physical for the patient history or risk for irregular pulse. PTS: 1 DIF: Cognitive Level: Application REF: 269 OBJ: Identify ranges of acceptable vital sign values for an adult, child, and infant TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 31. A nurse assesses a patient who has developed a febrile state. The nurse recalls that chills and shivers involve an alteration of the set point located in the: A. medulla. B. brainstem. C. hypothalamus. D. limbic system. ANS: C The medulla contains the cardiac, vasomotor, and respiratory control centers. The brainstem controls motor, sensory, and reflex functions for the body. The limbic system is associated with feelings and emotions. PTS: 1 DIF: Cognitive Level: Knowledge REF: 262 OBJ: Discuss physiological changes associated with fever TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 32. A patient is breathing rapidly. The nurse’s most appropriate response would be to: A. take the patient’s radial pulse. B. count the patient’s respirations. C. take a measurement of the patient’s oxygen saturation level. D. ask the patient if any situations have contributed to this response. ANS: C The radial pulse indicates cardiac rate. Counting respirations will enable you to assess if this response is normal or abnormal for the patient. A number of conditions will cause both normal and abnormal increase in respiratory rate. PTS: 1 DIF: Cognitive Level: Analysis REF: 279 OBJ: Describe factors that cause variations in vital signs TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity SHORT ANSWER 1. A postoperative patient is shivering. The nurse recalls that this mechanism is ____________. ANS: an involuntary response that increases heat production Physiological and behavioral mechanisms act to regulate and control body temperature. The body produces additional heat when the body experiences voluntary movements, involuntary shivering, and nonshivering thermogenesis. The basal metabolic rate is dependent on body surface area. PTS: 1 DIF: Cognitive Level: Knowledge REF: 262 OBJ: Discuss physiological changes associated with fever TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity MULTIPLE RESPONSE 1. A postoperative patient stands up and begins to feel faint. The nurse should do which of the following? Select all that apply. A. Have the patient lie down. B. Have the patient try to stand again later. C. Attempt to listen to the Korotkoff sounds. D. Listen to the patient’s apical pulse with the bell of a stethoscope. E. Expect the sitting blood pressure to be lower than the standing blood pressure. ANS: A, B Orthostatic hypotension occurs when a patient with a normal blood pressure develops symptoms (e.g., lightheadedness or dizziness) and low blood pressure when rising to an upright position. Korotkoff sounds are heard as rhythmic tapping that corresponds to the pulse. The apical pulse is auscultated with the diaphragm, which hears high-pitched sounds. The sitting blood pressure will be higher than the standing blood pressure. PTS: 1 DIF: Cognitive Level: Application REF: 273 OBJ: Describe factors that cause variations in vital signs TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity