NR224 WEEK 2: VITAL SIGNS AND
PHYSICAL ASSESSMENT
FOUNDATIONS
1. Which physiological mechanism is primarily responsible for heat loss through the
conversion of liquid to a gas?
A. Radiation
B. Conduction
C. Evaporation
D. Convection
Answer: C
Conceptual Explanation: Evaporation is the transfer of heat energy when a liquid is
changed to a gas, such as through diaphoresis.
2. A patient presents with a body temperature of 104°F (40°C). Which neurological structure
is likely failing to regulate the set-point?
A. Thalamus
B. Hypothalamus
,C. Medulla Oblongata
D. Pons
Answer: B
Conceptual Explanation: The hypothalamus acts as the body’s thermostat, maintaining
the set-point for core temperature.
3. When assessing a patient with a history of cardiac dysrhythmias, which method is most
accurate for determining heart rate?
A. Palpating the radial pulse for 30 seconds
B. Using an electronic blood pressure cuff
C. Auscultating the apical pulse for 60 seconds
D. Counting the carotid pulse for 15 seconds
Answer: C
Conceptual Explanation: Auscultation of the apical pulse for a full minute is the gold
standard for patients with irregular rhythms.
4. A nurse notes a pulse deficit in a patient. How is this calculated?
A. Subtracting the radial pulse rate from the apical pulse rate
B. Subtracting the diastolic pressure from the systolic pressure
C. Adding the apical and radial rates and dividing by two
, D. Subtracting the respiratory rate from the heart rate
Answer: A
Conceptual Explanation: A pulse deficit occurs when the heart contracts but doesn’t reach
the periphery; it is the difference between the apical and radial pulses.
5. Which factor would most likely cause a falsely low blood pressure reading?
A. Cuff wrapped too loosely
B. Cuff that is too narrow for the arm
C. Deflating the cuff too slowly
D. Arm positioned above the level of the heart
Answer: D
Conceptual Explanation: Positioning the arm above heart level leads to a false low
reading due to the effects of gravity on hydrostatic pressure.
6. A patient is experiencing Cheyne-Stokes respirations. What does the nurse expect to
observe?
A. Deep, rapid breathing without pauses
B. Prolonged gasping inspirations followed by short expirations
C. Rhythmic waxing and waning of breathing with periods of apnea
D. Consistently shallow breathing with occasional sighs
PHYSICAL ASSESSMENT
FOUNDATIONS
1. Which physiological mechanism is primarily responsible for heat loss through the
conversion of liquid to a gas?
A. Radiation
B. Conduction
C. Evaporation
D. Convection
Answer: C
Conceptual Explanation: Evaporation is the transfer of heat energy when a liquid is
changed to a gas, such as through diaphoresis.
2. A patient presents with a body temperature of 104°F (40°C). Which neurological structure
is likely failing to regulate the set-point?
A. Thalamus
B. Hypothalamus
,C. Medulla Oblongata
D. Pons
Answer: B
Conceptual Explanation: The hypothalamus acts as the body’s thermostat, maintaining
the set-point for core temperature.
3. When assessing a patient with a history of cardiac dysrhythmias, which method is most
accurate for determining heart rate?
A. Palpating the radial pulse for 30 seconds
B. Using an electronic blood pressure cuff
C. Auscultating the apical pulse for 60 seconds
D. Counting the carotid pulse for 15 seconds
Answer: C
Conceptual Explanation: Auscultation of the apical pulse for a full minute is the gold
standard for patients with irregular rhythms.
4. A nurse notes a pulse deficit in a patient. How is this calculated?
A. Subtracting the radial pulse rate from the apical pulse rate
B. Subtracting the diastolic pressure from the systolic pressure
C. Adding the apical and radial rates and dividing by two
, D. Subtracting the respiratory rate from the heart rate
Answer: A
Conceptual Explanation: A pulse deficit occurs when the heart contracts but doesn’t reach
the periphery; it is the difference between the apical and radial pulses.
5. Which factor would most likely cause a falsely low blood pressure reading?
A. Cuff wrapped too loosely
B. Cuff that is too narrow for the arm
C. Deflating the cuff too slowly
D. Arm positioned above the level of the heart
Answer: D
Conceptual Explanation: Positioning the arm above heart level leads to a false low
reading due to the effects of gravity on hydrostatic pressure.
6. A patient is experiencing Cheyne-Stokes respirations. What does the nurse expect to
observe?
A. Deep, rapid breathing without pauses
B. Prolonged gasping inspirations followed by short expirations
C. Rhythmic waxing and waning of breathing with periods of apnea
D. Consistently shallow breathing with occasional sighs
