Chapter 06: Vital Signs and Pain Assessment
MULTIPLE CHOICE
1. The pyrexia response is triggered by the production and release of:
a. prostaglandins.
b. endogenous pyrogens.
c. hypothalamic enzymes.
d. thyroid hormones.
ANS: A
When microorganisms invade the body, pyrogens are released and travel to the hypothalamus. The
pyrexia response is then triggered by the production and release of prostaglandins.
DIF: Cognitive Level: Understanding (Comprehension)
OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation
2. During expiration, the internal intercostals:
a. increase the force of muscular contraction.
b. decrease the lateral diameter during expiration.
c. decrease the intrathoracic space.
d. increase elastic recoil during expiration.
ANS: B
The diaphragm is the dominant muscle during respiration. It contracts and pushes downward during
inspiration to increase the intrathoracic space. The external intercostal muscles increase the AP
diameter during inspiration and the internal intercostals decrease the lateral diameter
during expiration.
DIF: Cognitive Level: Understanding (Comprehension)
OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation
3. The fifth vital sign is:
a. pain.
b. orientation.
c. waist-to-hip ratio.
d. body mass index (BMI).
ANS: A
Pain, the universal distress signal, is now recognized as the fifth vital sign.
DIF: Cognitive Level: Remembering (Knowledge)
OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation
4. The Joint Commission (TJC) requires that:
a. pain be assessed on all discharges.
b. repeated assessment of pain be limited to those patients who complain of pain.
, c. repeated intensity documentation be made of the course of pain relief for all patients.
d. pain be assessed on surgical patients.
ANS: C
MULTIPLE CHOICE
1. The pyrexia response is triggered by the production and release of:
a. prostaglandins.
b. endogenous pyrogens.
c. hypothalamic enzymes.
d. thyroid hormones.
ANS: A
When microorganisms invade the body, pyrogens are released and travel to the hypothalamus. The
pyrexia response is then triggered by the production and release of prostaglandins.
DIF: Cognitive Level: Understanding (Comprehension)
OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation
2. During expiration, the internal intercostals:
a. increase the force of muscular contraction.
b. decrease the lateral diameter during expiration.
c. decrease the intrathoracic space.
d. increase elastic recoil during expiration.
ANS: B
The diaphragm is the dominant muscle during respiration. It contracts and pushes downward during
inspiration to increase the intrathoracic space. The external intercostal muscles increase the AP
diameter during inspiration and the internal intercostals decrease the lateral diameter
during expiration.
DIF: Cognitive Level: Understanding (Comprehension)
OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation
3. The fifth vital sign is:
a. pain.
b. orientation.
c. waist-to-hip ratio.
d. body mass index (BMI).
ANS: A
Pain, the universal distress signal, is now recognized as the fifth vital sign.
DIF: Cognitive Level: Remembering (Knowledge)
OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation
4. The Joint Commission (TJC) requires that:
a. pain be assessed on all discharges.
b. repeated assessment of pain be limited to those patients who complain of pain.
, c. repeated intensity documentation be made of the course of pain relief for all patients.
d. pain be assessed on surgical patients.
ANS: C
