BSN 206 Quiz 2 Vital Signs and Physical
Assessment Protocols (Module 2 T0
QUESTIONS AND CORRECT ANSWERS
WITH RATIONALES)
covers core competencies in tracking cardiovascular, respiratory, and metabolic homeostasis.
1. Which arterial site is most commonly utilized to assess an adult client's routine baseline
pulse rate?
A) Brachial
B) Carotid
C) Popliteal
D) Radial
Rationale: The radial artery at the wrist is easily accessible, safe, and reliable for routine
peripheral pulse checks in stable adult clients.
1. A nurse is evaluating a patient with a core body temperature of 102.2°F (39°C). Which
term correctly describes this state?
A) Hypothermia
B) Normothermia
C) Pyrexia
D) Bradycardia
Rationale: Pyrexia, or fever, refers to an elevation in core body temperature above the
normal homeostatic range due to a reset of the hypothalamic setpoint.
1. To ensure an accurate tympanic temperature measurement in an infant under 3 years old,
the nurse must pull the pinna:
A) Upward and backward
B) Downward and backward
C) Straight forward
D) Upward and forward
Rationale: Due to anatomical differences in infants and young children, the pinna must be
pulled down and back to straighten the auditory canal.
1. What is the clinical consequence of using a blood pressure cuff with a bladder that is too
narrow for the patient's arm?
A) A false-low blood pressure reading
B) An accurate systolic reading but a false-low diastolic reading
C) A false-high blood pressure reading
, D) No measurable alteration in pressure dynamics
Rationale: A cuff that is too narrow or small requires excessive inflation pressure to
occlude the brachial artery, resulting in a falsely elevated reading.
1. A nurse observes that an adult patient's respiratory rate is 8 breaths per minute. This
finding is documented as:
A) Tachypnea
B) Eupnea
C) Apnea
D) Bradypnea
Rationale: Bradypnea is a respiratory rate slower than the normal adult parameter of 12–
20 breaths per minute.
1. Which phase of the Korotkoff sounds represents the distinct, sharp tapping sound that
indicates the adult systolic blood pressure?
A) Phase I
B) Phase II
C) Phase III
D) Phase IV
Rationale: Phase I Korotkoff sounds mark the first clear, rhythmic tapping sound heard as
blood begins to flow back through the deflating cuff, identifying systolic pressure.
1. A patient's pulse is described as irregular, skips beats, and demonstrates an unequal
interval pattern. The nurse identifies this as:
A) Pulse deficit
B) Dysrhythmia
C) Tachycardia
D) Pulsus paradoxus
Rationale: A dysrhythmia (or arrhythmia) is any deviation or irregularity in the normal
rhythm of the heartbeat.
1. When a nurse notes a discrepancy between a patient's simultaneous apical and radial
pulse counts, this difference is called the:
A) Pulse deficit
B) Pulse pressure
C) Mean arterial pressure
D) Stroke volume deviation
Rationale: A pulse deficit occurs when cardiac contractions are too weak to transmit a
pulse wave to the peripheral radial site, computed by subtracting the radial rate from the
apical rate.
Assessment Protocols (Module 2 T0
QUESTIONS AND CORRECT ANSWERS
WITH RATIONALES)
covers core competencies in tracking cardiovascular, respiratory, and metabolic homeostasis.
1. Which arterial site is most commonly utilized to assess an adult client's routine baseline
pulse rate?
A) Brachial
B) Carotid
C) Popliteal
D) Radial
Rationale: The radial artery at the wrist is easily accessible, safe, and reliable for routine
peripheral pulse checks in stable adult clients.
1. A nurse is evaluating a patient with a core body temperature of 102.2°F (39°C). Which
term correctly describes this state?
A) Hypothermia
B) Normothermia
C) Pyrexia
D) Bradycardia
Rationale: Pyrexia, or fever, refers to an elevation in core body temperature above the
normal homeostatic range due to a reset of the hypothalamic setpoint.
1. To ensure an accurate tympanic temperature measurement in an infant under 3 years old,
the nurse must pull the pinna:
A) Upward and backward
B) Downward and backward
C) Straight forward
D) Upward and forward
Rationale: Due to anatomical differences in infants and young children, the pinna must be
pulled down and back to straighten the auditory canal.
1. What is the clinical consequence of using a blood pressure cuff with a bladder that is too
narrow for the patient's arm?
A) A false-low blood pressure reading
B) An accurate systolic reading but a false-low diastolic reading
C) A false-high blood pressure reading
, D) No measurable alteration in pressure dynamics
Rationale: A cuff that is too narrow or small requires excessive inflation pressure to
occlude the brachial artery, resulting in a falsely elevated reading.
1. A nurse observes that an adult patient's respiratory rate is 8 breaths per minute. This
finding is documented as:
A) Tachypnea
B) Eupnea
C) Apnea
D) Bradypnea
Rationale: Bradypnea is a respiratory rate slower than the normal adult parameter of 12–
20 breaths per minute.
1. Which phase of the Korotkoff sounds represents the distinct, sharp tapping sound that
indicates the adult systolic blood pressure?
A) Phase I
B) Phase II
C) Phase III
D) Phase IV
Rationale: Phase I Korotkoff sounds mark the first clear, rhythmic tapping sound heard as
blood begins to flow back through the deflating cuff, identifying systolic pressure.
1. A patient's pulse is described as irregular, skips beats, and demonstrates an unequal
interval pattern. The nurse identifies this as:
A) Pulse deficit
B) Dysrhythmia
C) Tachycardia
D) Pulsus paradoxus
Rationale: A dysrhythmia (or arrhythmia) is any deviation or irregularity in the normal
rhythm of the heartbeat.
1. When a nurse notes a discrepancy between a patient's simultaneous apical and radial
pulse counts, this difference is called the:
A) Pulse deficit
B) Pulse pressure
C) Mean arterial pressure
D) Stroke volume deviation
Rationale: A pulse deficit occurs when cardiac contractions are too weak to transmit a
pulse wave to the peripheral radial site, computed by subtracting the radial rate from the
apical rate.
