test-bank-for-essentials-for-nursing-practice-8th-edition-by-potter-chapter-15-vital-signs

test-bank-for-essentials-for-nursing-practice-8th-edition-by-potter-chapter-15-vital-signs Chapter 15: Vital Signs Potter: Essentials for Nursing Practice, 8th Edition MULTIPLE CHOICE 1.The nursing student is obtaining the patients vital signs. The patient has gone to the clinic seeking help because she is having chest pain. Which of the following vital signs are most important 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 patients pain helps a nurse understand the patients clinical status and progress. PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:270 OBJ:Accurately assess body temperature, pulse, respiration, oxygen saturation, and blood pressure.TOP:Nursing Process: Diagnosis MSC: NCLEX: Management of Care 2.Upon a patients admission to the nursing unit, the registered nurse delegated to the nursing assistive personnel to take her vital signs. What is the registered nurses responsibility regarding delegating this task? a. This is inappropriate delegation; the nurse should always take the vital signs b. Have the NAP repeat the measurement if vital signs appear abnormal. c. The nurse should review and interpret the vital sign measurements. d. This task has been delegated so the nurse is not responsible. ANS: A nurse may delegate the measurement of selected vital signs (e.g., stable patients) to nursing assistive personnel. However, it is the nurses responsibility to review vital sign data, interpret their significance, and critically think through decisions about interventions. When vital signs appear abnormal, repeat the measurement. When caring for a patient, the nurse is responsible for vital sign monitoring. PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:271 OBJ: Correctly delegate vital sign measurement to nursing assistive personnel. TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care 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 health care provider because the patients values differ from the stan b. Immediately call the health care provider and request antihypertensive medic c. Ask the patient what his blood pressure normally measures for comparison. d. Do nothing; this is within a normal range for a patient with diabetic ketoacido ANS: C Know the patients usual range of vital signs. A patients usual values sometimes differ from the standard range for that age or physical state. Use the patients usual values as a baseline for comparison with findings taken later. A single measurement does not adequately reflect a patients blood pressure. Blood pressure trends, not individual measurements, guide your nursing interventions. Hypertension is defined as systolic blood pressure (SBP) greater than 140 mm Hg, diastolic blood pressure (DBP) greater than 90 mm Hg PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:271 | 282 OBJ:Accurately assess body temperature, pulse, respiration, oxygen saturation, and blood pressure.TOP:Nursing Process: Diagnosis MSC: NCLEX: Management of Care 4.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 100.6 F. 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. Shivering is a more effective way to dissipate heat energy. c. Corticosteroids are safer to use than antipyretics. 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 adults fever until it is higher than 39 C (102.2 F). For healthy young adults the average oral temperature is 37 C (98.6 F). In the elderly population, the average core temperature ranges from 35 to 36.1 C (95 to 97 F) because of decreased immunity. Shivering is counterproductive because of the heat produced by muscle activity. Although not used to treat fever, corticosteroids reduce heat production by interfering with the hypothalamic response. It is important to note that these drugs mask signs of infection by suppressing the immune system. PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF: 173 | 174 OBJ: Explain the principles and mechanisms of thermoregulation. TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care 5.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 which of the following? a. Convection b. Radiation c. Conduction d. Evaporation ANS: C Heat loss occurs through conduction, which is the transfer of heat from one object to another with direct contact. When the warm skin touches a cooler object, heat transfers from the skin to the object until temperatures equalize. Convection is the transfer of heat away from the body by air movement. Fans promote heat loss through convection. 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: Understanding (Comprehension) REF:273 OBJ: Describe nursing interventions that promote heat loss and heat conservation. TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care 6.A 6-year-old was taken to the hospital after having a seizure at home. The patients mother tells the nurse that she has been ill for the past week and has had a fever with nausea and vomiting. The patients mother believes that the seizure was caused by a fever of 99.5 F, which the patient had during the course of her illness. What is the nurses best response? a. With a temperature that high, we can only hope that there is no permanent d b. Fevers in this range are part of the bodys natural defense system c. Febrile seizures are common in children Nancys age. d. The child will need antibiotics. Does she have any allergies? ANS: B Fever serves as an important defense mechanism. Therefore most health care providers will not treat an adults fever until it is greater than 39 C (102.2 F). A fever is usually not harmful if it stays below 39 C (102.2 F) in adults or 40 C (104 F) in children. 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: Understanding (Comprehension) REF: 274 | 275 OBJ: Discuss physiological changes associated with fever. TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care 7.A 5-year-old child was admitted for a diagnosis of meningitis with a fever of 104.5 F and nuchal rigidity. She responded to antipyretics that were ordered. In addition, the patients mother was asked to help reduce the fever by limiting the number of blankets covering the patient. After interventions, the childs temperature is 100.5 F. The nurse recognized that the mother has an understanding of the patients condition when she states which of the following? a. The high temperature is useful in fighting bacteria and viruses as long as its n b. You need to get her temperature down quickly. Shes so uncomfortable. c. Her fever is dropping because she is shivering. She must be cold. d. She probably picked up a bacteria. Thats what kids do. Thats why they get inf ANS: A A fever is usually not harmful if it stays below 39 C (102.2 F) in adults or 40 C (104 F) in children. Increased temperature reduces the concentration of iron in the blood plasma, causing bacterial growth to slow. Fever also fights viral infections by stimulating interferon, the bodys natural virusfighting substance. The goal is a safe rather than a low temperature. A true fever results from an alteration in the hypothalamic set point. To reach the new set point, the body produces and conserves heat. The patient experiences chills, shivers, and feels cold, even though the body temperature is rising. Most fevers in children are of viral origin, lasting only briefly, and have limited effects PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF: 273 | 274 OBJ: Discuss physiological changes associated with fever. TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care 8.The young mother of an 8-month-old patient brought her daughter to the clinic after taking the little girls 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? a. Children usually run lower rather than higher temperatures when ill. b. Because of her age, it is probably a bacterial infection. c. Rectal temperatures are higher than temperatures obtained orally. d. When taking multiple temperatures, the sites should be rotated. ANS: C Depending on the site, temperatures will normally vary between 36 C (96.8 F) and 38 C (100.4 F). It is generally accepted that rectal temperatures are usually 0.5 C (0.9 F) higher than oral temperatures. Children have immature temperature control mechanisms, so temperatures sometimes rise rapidly. Most fevers in children are of viral origin, lasting only briefly, and have limited effects. Use the same site when repeated measurements are needed. PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:273 | 274 | 275 OBJiscuss physiological changes associated with fever. TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care 9.A 6-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 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. Dehydration b. An allergic response to the prescribed medication c. Febrile seizures d. Fever of unknown origin (FUO) 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, hives, or itching. Treatment involves stopping the medication responsible for the reaction. Dehydration and febrile seizures occur during rising temperatures in children between 6 months and 3 years of age. Febrile seizures are unusual in children greater than 5 years of age. The term fever of unknown origin (FUO) refers to a fever whose cause cannot be determined. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 273 | 274 OBJ: Discuss physiological changes associated with fever. TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care 10. 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. Apply water cooled blankets. ANS: C Before antibiotic therapy, obtain blood cultures when ordered. Obtain blood specimens at the same time as a temperature spike, when the causative organism is most prevalent. Antipyretics are medications that reduce fever. It is important to note that these drugs mask signs of infection by suppressing the immune system. Physical cooling, including the use of water-cooled blankets, is appropriate when the patients own thermoregulation fails or in patients with neurological damage (e.g., spinal cord injury). PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:274 OBJ: Describe nursing interventions that promote heat loss and heat conservation. TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care