Foundations of Nursing Chapter 30 Vital Signs Exam

The registered nurse teaches the student nurse about the correct times to measure vital signs. Which statement by the student nurse shows ineffective learning? 1 "I will assess the vital signs during home care visits." 2 "I will assess the vital signs before, during, and after a surgical procedure." 3 "I will assess the vital signs of a patient who reports nonspecific symptoms of physical distress." 4 "I will assess the vital signs every hour when the physical condition of the patient worsens." - 4 Vital signs are the rapid and efficient way of monitoring a patient's condition. These signs help to identify problems and to evaluate the patient's response to interventions. The nurse is responsible for judging the frequency of assessment of these signs. The nurse should measure vital signs every five to 10 minutes when the physical condition of the patient worsens.The nurse should measure vital signs during home care visits. The vital signs should also be monitored before, during, and after a surgical procedure. When a patient reports nonspecific symptoms of physical distress, the nurse should assess the vital signs. Which statement is true regarding the pulse rate of an older adult? 1 Pedal pulse can easily be palpated in older adults. 2 Older adults have increased heart rate at rest. 3 It takes longer for the heart rate to rise in older adults during illness. 4 Heart sounds are sometimes muffled due to decreased air space in the lungs. - 3 It takes longer for the heart rate to rise in the older adults during illness to meet increased demands during conditions such stress, illness, and excitement. Pedal pulses are often difficult to palpate in older adults. Older adults have decreased heart rate at rest. Heart sounds are sometimes muffled or difficult to hear in older adults because of an increase in air space in the lungs. The nurse is measuring the vital signs of a patient. What is the normal range of pulse pressure? 1 10 to 15 mm Hg 2 20 to 25 mm Hg 3 30 to 50 mm Hg 4 60 to 70 mm Hg - 3 Pulse pressure is defined as the difference between the systolic and diastolic blood pressure normally ranging from 30 to 50 mm Hg. Any value below 30 mm of Hg and above 50 mm of Hg is considered to be outside the normal range. What consequence may occur due to kyphosis in an older patient? 1 Anorexia 2 Hyperthermia 3 Postural hypotension 4 Restricted chest expansion - 4 Kyphosis in older patients may restrict chest expansion. The subtle changes in temperature may cause anorexia. In older patients, decreased sweat gland reactivity may cause hyperthermia. Older patients are instructed to change position slowly to prevent postural hypotension. The nurse is teaching the nursing student about when to measure the vital signs in a patient. Which statement by the nursing student indicates the need for further learning? Select all that apply. 1 "Vital signs should be measured before ambulating a patient previously on bed rest." 2 "Vital signs should be measured before and after a transfusion of blood products." 3 "Vital signs should be measured after a patient reports increased intensity of pain." 4 "Vital signs should be measured before a patient performs range-of-motion exercises." 5 "Vital signs should be measured after the administration of medication that affects temperature control functions." - 2, 5 Vital signs should be measured before, during, and after a transfusion of blood products, not only before and after. During the blood transfusion, it is important to measure vital signs to check the occurrence of any complication due to transfusion rate or amount of blood product transfusion. Vital signs should be measured before, during, and after the administration of medication that affects temperature control functions, not only after. Before the administration of medication that affects temperature control, it is important to measure vital signs to determine whether the patient is really in need of that medication. During the administration of medication that affects temperature control, it is important to measure the vital signs to check for overdosing. Vital signs should be measured before a patient previously on the bed ambulates. Vital signs should be measured after a patient reports increased intensity of pain. Vital signs should be measured before a patient performs range-of-motion exercises. When does the respiratory system mature in healthy people? 1 25 years 2 20 years 3 35 years 4 50 years - 2 The respiratory system matures by the age of 20 years in healthy people. At the age of 25, the respiratory system starts to decline. At the ages of 35 and 50 years, people can breathe effortlessly as long as they are healthy. What is the acceptable range for diastolic blood pressure in a healthy adult? 1 Less than 120 mm Hg 2 Less than 80 mm Hg 3 30 to 50 mm Hg 4 35 to 45 mm Hg - 2 The acceptable range for diastolic blood pressure in a healthy adult is less than 80 mm Hg. Less than 120 mm Hg is the acceptable range for systolic blood pressure in a healthy adult. The normal range for pulse pressure in a healthy adult is 30 to 50 mm Hg. The normal range for capnography in a healthy adult is 35 to 45 mm Hg. While assessing the condition of a 70-year-old patient, the nurse observes decreased tidal volume. What is the likely reason for this observation? 1 Poor muscle control 2 Increased air space in lungs 3 Abnormal curvature of the spine 4 Decreased sweat gland reactivity - 3 Kyphosis is the abnormal curvature of the spine observed in older adults, which causes restriction of chest expansion and decreased tidal volume. Heart sounds are sometimes muffled or difficult to hear in older adults because of an increase in air space in the lungs. Poor muscle control does not cause decreased tidal volume. Decrease in sweat gland activity in older adults results in a higher threshold for sweating at high temperature and leads to hyperthermia and heatstroke. The nurse is assessing a patient's vital signs. After assessment, the nurse immediately reports an unstable vital sign to the health care provider. What finding in the patient alerts the nurse to a deviation from the normal range? 1 Pulse pressure of 50 mm Hg 2 Rectal temperature of 99.5° F (37.5° C) 3 Pulse rate of 62 beats per minute 4 Respiratory rate of 11 breaths per minute - 4 The normal acceptable range of respiratory rate is between 12 and 20 breaths per minute; hence, the patient has a reduced respiratory rate (bradypnea). The normal range of pulse pressure is between 30 and 50 mm Hg. The average rectal temperature is 99.5° F (37.5° C). The pulse rate of a normal patient should be in the range of 60 to 100 beats per minute. A 60-year-old male patient complains of severe breathlessness, sweating, pain in the chest, and cough. What guidelines should the nurse follow when measuring the vital signs? Select all that apply. 1 Measure the vital signs four times per day. 2 Determine the patient's medical history. 3 Use equipment that is appropriate per the age of the patient. 4 Report all changes in vital signs to the health care provider. 5 Use vital sign measurements to determine indications for medication administration. - 2, 3, 5 The nurse should know the patient's medical history to know which vital signs would be affected by medications, environmental factors, or the ability to detect complications. Proper equipment per the age of the patient should be used to prevent errors. The vital signs should be used as an indicator for administration of medication. For example, certain cardiac drugs would be used only within a range of pulse of blood pressure values. The frequency of measuring the vital signs has to be discussed with the primary health care provider. It is not necessary to immediately report changes in the vital signs to the healthcare provider unless the change is significant. A hypertensive patient expresses that he is too busy to go to a clinic to have his blood pressure taken. The patient wishes to monitor his blood pressure on his own. What should the nurse educate this patient about the electronic sphygmomanometer? Select all that apply. 1 It is difficult to manipulate. 2 It requires frequent recalibration. 3 It does not require the use of a stethoscope. 4 It may give an incorrect reading with movement of the arm. 5 It does not give a false reading with improper cuff placement. - 2, 3, 4 The electronic sphygmomanometer requires frequent recalibration, at least more than once in a year, to ensure accuracy. These devices do not require the use of a stethoscope because they are electronic. The device is very sensitive to the movement of the arm, and may give a false reading. Electronic sphygmomanometers are simple and easy to operate. They may give false readings if the cuff is not placed properly. Which vital values in a patient are abnormal? Select all that apply. 1 Pulse oximetry 92% 2 Pulse pressure 60 mm Hg 3 Axillary temperature 97.7° F 4 Pulse rate 80 beats per minute 5 Respiratory rate 18 breaths per minute - 1, 2 The normal range of pulse oximetry in an adult is SpO2 ≥ 95%; therefore, a pulse oximetry value of 92% is low. The normal range of pulse pressure in an adult is 30-50 mm Hg; therefore, a pulse pressure value of 60 mm Hg is high. The average axillary temperature in a normal adult is 36.5° C (97.7° F). The normal range of pulse rate in an adult is 60-100 beats per minute. The normal range of respiratory rate in an adult is 12-20 breaths per minute. Which statement is true regarding the radiation heat loss mechanism of the body? 1 Peripheral vasodilation minimizes radiant heat loss. 2 Radiation is the transfer of heat from one object to another without direct contact. 3 Radiation increases as the temperature difference between the objects decreases. 4 The body absorbs heat through radiation if the environment is warmer than the skin. - 2 Radiation is a heat loss mechanism of the body. If the environment is warmer compared to the skin, the body absorbs heat through radiation without any direct contact. Peripheral vasodilation increases the blood flow from the internal organs to the skin to increase radiant heat loss. Radiation is the transfer of heat from the surface of one object to the surface of another without direct contact between them. Radiation increases as the temperature difference between the objects increases. At which age does the respiratory system begin to decline in healthy people? 1 20 years 2 25 years 3 45 years 4 60 years - 2 The respiratory system begins to decline in healthy people after the age of 25. The respiratory system matures by the time a person reaches 20 years of age. Despite the decline in adults at 45 and 60 years of age, they can breathe effortlessly as long as they are healthy. Which manifestation is often called the fifth vital sign? 1 Pain 2 Pulse 3 Temperature 4 Blood pressure - 1 Pain, a subjective symptom, is often called the fifth vital sign because it is an indicator of health status and, therefore, it is frequently measured with other vital signs. Pulse, temperature, blood pressure, and respiration are the main vital signs because they indicate the effectiveness of circulatory, respiratory, neural, and endocrine body functions. The nurse is caring for a patient who underwent a hysterectomy. In which situation should the nurse measure the vital signs? Select all that apply. 1 When the patient eats 2 During the infusion of blood products 3 When the patient has decreased pain intensity 4 When the patient reports that she feels "different" 5 Before the patient performs range-of-motion exercises - 2, 4, 5 The nurse should measure the vital signs before, during, and after the transfusion of blood products. The vital signs should be measured when the patient reports nonspecific symptoms of physical distress, such as feeling "funny" or "different." The nurse should measure vital signs in case of conditions that may influence vital signs, such as before performing range-of-motion (ROM) exercises, because the vital signs may vary while performing ROM exercises. The nurse would not measure vital signs when the patient is eating because eating would not have any influence on vital signs. The nurse should measure vital signs when the patient has increased intensity of pain, not decreased intensity. Which symptom is associated with an elevated temperature? 1 Cyanosis 2 Chest pain 3 Diaphoresis 4 Shortness of breath - 3 Along with the actual vital signs, there will be symptoms accompanied with it. Elevated body temperature results in diaphoresis. Cyanosis is associated with hypoxemia. Chest pain occurs due to abnormal blood pressure. Abnormal respirations result in shortness of breath. The nurse decides not to measure the temperature of an older adult using the oral site. What is the likely reason for this decision? Select all that apply. 1 Patient has no teeth 2 Patient has a rigid rib cage 3 Patient has poor muscle control 4 Patient's ribs are downward-slanted 5 Patient's sweat gland reactivity is decreased - 1, 3 The oral temperature for older adults may be inaccurate due to an inability to close the mouth completely, which may occur due to the absence of teeth and poor muscle control. The rigidity of the rib cage may cause chest wall expansion. The patient with downward-slanted ribs may have restricted chest expansion and decreased tidal volume. A patient with decreased sweat gland reactivity may suffer hyperthermia and heat stroke. Which vital parameter may be altered due to decreased vessel elasticity? 1 Pulse rate 2 Blood pressure 3 Respiratory rate 4 Body temperature - 2 Decreased vessel elasticity will alter the systolic blood pressure. Pulse rate, respiratory rate, and body temperature are not altered by decreased vessel elasticity. What is the average rectal temperature of a 35-year-old adult? 1 36.5° C (97.7° F) 2 37° C (98.6° F) 3 37.5° C (99.5° F) 4 38° C (100.4° F) - 3 The average rectal temperature of adults is 99.5° F. The axillary temperature of adults is 97.7° F. The average oral or tympanic temperature of adults is 98.6° F. Normal temperature range is between 96.8 and 100.4° F. What is the acceptable tympanic body temperature for adults? 1 36° C (96.8° F) 2 36.5° C (97.7° F) 3 37° C (98.6° F) 4 37.5° C (99.5° F) - 3 The average tympanic temperature for adults is 37° C (98.6° F). A body temperature of 96.8° F is within the normal range for adults. The average axillary temperature for adults is 36.5° C (97.7° F). The average rectal temperature for adults is 37.5° C (99.5° F). The blood pressure of an older patient is 150/90 mm Hg. What could be the pulse pressure in this patient? Record the answer using a whole number. _______ mm Hg - 60 Pulse pressure is the difference between systolic and diastolic blood pressure. Therefore, 150 - 90 mm Hg = 60 mm Hg, which is the pulse pressure in the patient. Which statements are true regarding the factors affecting vital signs of older adults? Select all that apply. 1 It is important to pay attention to subtle temperature changes in older adults. 2 Older adults are very sensitive to slight changes in environmental temperature. 3 A decrease in sweat gland reactivity in older adults may lead to hyperthermia. 4 The oral site is best for taking accurate temperature readings in older adults. 5 The temperature of the older adult is at the upper end of the normal temperature range. - 1, 2, 3 It is important to be attentive to subtle temperature changes and other manifestations of fever in older adults. Older adults are very sensitive to slight changes in environmental temperature, because their thermoregulatory systems are not as efficient. A decrease in sweat gland reactivity in the older adults results in a higher threshold for sweating at high temperatures that leads to hyperthermia and heatstroke. Older adults are often missing teeth and have poor muscle control; therefore, they may be unable to close their mouth tightly to obtain accurate oral temperature readings. The temperature of older adults is at the lower end of the normal temperature range. The registered nurse delegated the task of palpating the pulse of a 75-year-old obese patient to a licensed practical nurse (LPN). Which device used by the LPN would be appropriate to obtain more accurate readings in this patient? 1 Apnea monitor 2 Pulse oximeter 3 Doppler device 4 Vinyl pressure cuff - 3 A Doppler device is used to palpate the pulse of an older adult who is obese because it provides more accurate readings. An apnea monitor is a device used to measure respiratory rate. A pulse oximeter is used to measure oxygen saturation and the values obtained with this device are less accurate. The vinyl pressure cuff is used to measure blood pressure. While assessing the pulse rate of an 80-year-old patient, the nurse has difficulty hearing the heart sounds of the patient. What could be the reason for the muffled heart sounds? 1 Increased heart rate 2 Decreased vessel elasticity 3 Increased air space in lungs 4 Ossification of costal cartilage - 3 Heart sounds maybe muffled or difficult to hear in older adults due to an increase in air space in the lungs. An increase in heart rate would show differences in pulse rate, not differences in heart sounds. Older adults may experience an increase in systolic pressure due to decreased vessel elasticity. Ossification of costal cartilage for older adults results in reduced chest wall expansion. The registered nurse is teaching a nursing student about the assessment of vital signs in older adults. Which statement by the nursing student indicates the need for further teaching? 1 "I should use a large cuff to measure blood pressure." 2 "I should instruct the patient to slowly change his or her position." 3 "I should assess the skin while frequently monitoring the blood pressure." 4 "I should rotate the sites for measurement of blood pressure for frequent monitoring of blood pressure." - 1 Older adults usually lose upper arm mass and require a smaller blood pressure cuff. Changing the patient's position will help reduce the risk of postural hypotension. The skin of older adults is more fragile and susceptible to cuff pressure during frequent measurements. Therefore, it is advised to make frequently assess the skin under the cuff and rotate blood pressure sites. Which site is preferred for assessing the heart rate in a patient? 1 Apical 2 Radial 3 Carotid 4 Temporal - 2 The radial site is used to assess the status of circulation and is the preferred site when assessing the heart rate in a patient. The carotid site is present in the neck along the medial edge of the sternocleidomastoid muscle. The pulse rate is assessed from the carotid site when other sites are not palpable in a patient with cardiac arrest. The apical site is used to assess apical pulse rate. The temporal site is used to assess pulse rate in children. A registered nurse is asking the nursing student to list the mechanisms that would occur in a patient when the posterior hypothalamus senses that the body temperature is lower than the set point. Which mechanisms listed by the student indicate effective learning? Select all that apply. 1 Muscle shivering 2 Excessive sweating 3 Narrowing of blood vessels 4 Inhibition of heat production 5 Voluntary muscle contraction - 1, 3, 5 The posterior hypothalamus senses if the body temperature drops below the set point, at which point the body then initiates heat-conservation mechanisms. Shivering is the mechanism that occurs when vasoconstriction is ineffective in preventing heat loss. Vasoconstriction, or narrowing of blood vessels, is a heatconservation mechanism that reduces blood flow to the skin and extremities. Voluntary muscle contraction is a compensatory heat production mechanism. Excessive sweating and vasodilation are the heat loss mechanisms that are controlled by the anterior hypothalamus. A patient has delivered a baby at full term. What does the nurse teach the patient about protecting newborns from environmental temperature? Select all that apply. 1 Teach the importance of adequate clothing. 2 Emphasize covering the head of the baby with a cap. 3 Explain that extra care is not required for full-term babies. 4 Instruct the patient to avoid exposing infants to extreme temperatures. 5 Encourage the patient to keep the baby's body temperature above 99.5° F (37.5° C). - 1, 2, 4 The temperature control mechanism of newborn babies is immature, and babies respond drastically to environmental temperatures. Hence, babies should be adequately clothed, and the head of the baby should be covered by a cap to prevent heat loss. Newborn babies should not be exposed to extreme temperatures; extreme temperatures can harm them. The body temperature should be kept between 95.9° F (35.5° C) and 99.5° F (37.5 ° C), because this is the normal range of body temperature for newborns; temperatures above 99.5° F (37.5 ° C) indicate fever. A woman experiences a rise in body temperature during ovulation. Which hormone is responsible for this? 1 Inhibin 2 Estrogen 3 Progesterone 4 Luteinizing hormone - 3 Ovulation is associated with the release of greater amounts of progesterone into circulation, which is responsible for raising body temperature. Inhibin, estrogen, and luteinizing hormone have no role in raising body temperature. Inhibin inhibits the synthesis and secretion of follicle-stimulating hormone. Estrogen is the female sex hormone responsible for development of secondary sexual characteristics in females and regulation of the menstrual cycle. Luteinizing hormone triggers the process of ovulation. The nurse is teaching a patient who is taking antihypertensive drugs about the management of hypertension. Which statement would indicate that the patient understands the management of hypertension? 1 "I need to have my blood pressure checked monthly." 2 "I can still smoke while taking these drugs as long as I cut down." 3 "These pills will help control my high blood pressure." 4 "When my blood pressure is back to normal, I can stop taking these pills." - 3 The drug therapy for high blood pressure does not cure the disease; it only helps control the symptoms. Patients should check blood pressure regularly, report significant changes, and avoid the use of tobacco in any form. The blood pressure would return to normal with the drug therapy; however, therapy should not be stopped or hypertension may return. The registered nurse is teaching a nursing student about the advantages and disadvantages of selecting temperature measurement sites. Which statement by the nursing student indicates the need for further teaching? 1 "The rectal site for temperature measurement requires lubrication." 2 "Skin is a safe and non-invasive site for temperature measurement." 3 "The oral site for temperature measurement is contraindicated in infants and children." 4 "The tympanic membrane site is easily accessible without changing position to measure temperature." - 4 The tympanic membrane site is easily accessible for measuring body temperature, but it requires minimal repositioning of the patient. The rectal site for temperature measurement may have a risk of body fluid exposure and injury to the rectal lining. Therefore, before assessing temperature, the site should be lubricated. Skin is a safe noninvasive site for temperature measurement. The oral site for temperature measurement is not used for infants, small children, or patients who are confused, unconscious, or uncooperative. The nurse is learning about different types of fevers. Which statements are true about relapsing fever? Select all that apply. 1 It includes periods of febrile episodes and periods with acceptable temperature values. 2 Febrile episodes and periods of normothermia are often longer than 24 hours. 3 It is typified by a constant body temperature continuously above 100.4° F (38° C) and has little fluctuation. 4 It includes fever spikes interspersed with usual temperature levels. 5 It includes fever spikes and falls without a return to normal temperature levels. - 1, 2, 4 A relapsing fever is characterized by periods of febrile episodes and periods with acceptable temperature values. These episodes often last longer than 24 hours. A sustained body temperature continuously above 100.4° F (38° C) with little fluctuation is called a sustained fever. An intermittent fever is characterized by fever spikes interspersed with usual temperature levels. Fever spikes and falls without a return to normal temperature levels are found in remittent fever. A 56-year-old patient with diabetes admitted for community-acquired pneumonia has a temperature of 38.2° C (100.8° F) via the temporal artery. Which additional assessment data are needed in planning interventions for the patient's infection? Select all that apply. 1 Heart rate 2 Presence of diaphoresis 3 Smoking history 4 Respiratory rate 5 Recent bowel movement 6 Blood pressure in right arm 7 Patient's normal temperature 8 Blood pressure in distal extremity - 1, 2, 4, 7 To plan interventions for this patient's infection the nurse would need to know the patient's heart rate, presence of diaphoresis, respiratory rate, and the patient's normal temperature. The patient's bowel movement and blood pressure are not data that are integral to planning this patient's care. An elderly patient has recently shifted to a residence located at a high altitude and finds it difficult to cope with extreme temperatures. The patient feels that there is a body system problem because the patient experiences more cold than other people do. The nurse explains to the patient that this is a normal response to aging. What is the rationale for this response? Select all that apply. 1 "Aging increases metabolism." 2 "Aging causes poor vasomotor control." 3 "Aging increases sweat gland activity." 4 "Aging reduces subcutaneous tissue." 5 "Aging affects the temperature control mechanism." - 2, 4, 5 Elderly people have poor vasomotor control. There is inefficient vasomotor regulation in response to alterations in temperature. Fat and subcutaneous tissues play a major role in insulation. There is reduction of subcutaneous tissue in aging. The activity of the hypothalamus and thus the temperature control mechanism also deteriorates with aging. Metabolism and sweat gland activity decrease with aging, making the temperature control mechanism less effective. The registered nurse is teaching a nursing student about alterations in body temperature outside the normal range. Which statement by the nursing student indicates the need for further teaching? 1 "Bluish discoloration of the skin is noticed in patients with elevated body temperature." 2 "Ice crystals that form inside the cells of the patients with frostbite may cause tissue damage." 3 "Malignant hyperthermia is an inherited condition that results in uncontrollable heat production." 4 "Patients who are on diuretic and amphetamine medication therapy are at a high risk of heatstroke." - 1 Hypothermia is the condition in which the skin temperature drops below 34° C (or 93.2° F). The patient exhibits various signs, such as the bluish discoloration of the skin or cyanotic skin. Ice crystals formed inside the cells of the patients with frostbite may cause permanent circulatory damage or tissue damage. Malignant hyperthermia is a hereditary condition of uncontrolled heat production that occurs when susceptible people receive certain anesthetic drugs. Patients are at a risk of heatstroke when they are on medication therapy with certain drugs that decrease the ability of the body to lose heat, such as diuretics, amphetamines, and beta adrenergic receptor antagonists. The nurse notices intense body warmth and sweating lasting for up to 5 minutes in a 50-year-old woman. How does the nurse interpret these symptoms? 1 The nurse attributes them to menopause. 2 The nurse attributes them to neurogenic changes. 3 The nurse attributes them to increased estrogen. 4 The nurse attributes them to the presence of fever. - 1 Intense body warmth and sweating in a menopausal woman indicate that she is having hot flashes. They occur due to instability of the vasomotor controls for vasodilation and vasoconstriction. They are due to vascular changes and not due to neurogenic changes. In menopause, there is a decreased estrogen level. Hot flashes are a symptom of menopause, and may not be due to fever. The nurse is conducting a class on different temperature measurement sites. In which patients should the tympanic membrane be used as a site for temperature measurement? Select all that apply. 1 In patients who do not mind the removal of their hearing aids 2 In patients with otitis media 3 In patients who had surgery of the ear 4 In patients with cerumen impaction 5 In patients complaining of tachypnea - 1, 5 A tympanic thermometer is fast, safe, noninvasive, and can be used for patients complaining of tachypnea without affecting breathing. Hearing aids must be removed before measurement. Tympanic thermometers are not recommended for patients who have had a recent ear infection such as otitis media; using a tympanic thermometer may spread the infection and may measure inaccurately. Patients with cerumen impaction should not have their temperature measured through a tympanic thermometer, because it can give an erroneous reading. Surgery on the ear is a contraindication for use of the tympanic thermometer. The following blood pressures, taken 6 months apart, were from patients screened by the nurse at the assisted-living facility. Which patient should be referred to the healthcare provider for hypertension evaluation? 1 120/80, 118/78, 124/82 2 128/84, 124/86, 128/88 3 148/82, 148/78, 134/86 4 154/78, 118/76, 126/84 - 3 The definition of hypertension requires two elevated blood pressure measurements in a row (≥140 systolic pressure or ≥90 diastolic pressure). The other answers describe prehypertension. A patient reports to the nurse increased body temperature in the evening and decreased body temperature in the morning. What does the nurse educate this patient about normal circadian rhythms? Select all that apply. 1 "The highest body temperature occurs at around 4:00 pm." 2 "The lowest body temperature occurs between 1:00 am and 4:00 am." 3 "There will be alterations in circadian rhythm due to age." 4 "A normal body temperature change in a 24-hour period is 0.5° C and 1° C." 5 "Temperature patterns automatically reverse within one week of beginning to work a night shift." - 1, 2, 4 In a normal circadian rhythm, the normal body temperature is highest at around 4:00 pm and lowest between 1:00 am and 4:00 am. The temperature change during a 24-hour period is usually between 0.5° C and 1° C. The circadian temperature rhythm does not alter with age. In night-shift workers, the temperature pattern does not change automatically within one week of beginning the night shift. It takes up to 3 weeks for such a change to happen. A 10-year-old child is brought to the hospital with high fever and chills. The nurse records the vital signs and finds that her temperature is 104° F (40° C), blood pressure is 130/85 mm Hg, and pulse rate is 120/min. The fever remains mostly high but is interspersed with periods of normal body temperature. What pattern of fever does the child have? 1 Sustained 2 Intermittent 3 Remittent 4 Relapsing - 2 Intermittent fever is characterized by spikes in temperature coupled with periods of normal temperature that occur at least once every 24 hours. In a sustained fever, the fever is continuous. In a remittent pattern, the fever spikes and falls without a return to normal temperature. In a relapsing fever, the fever lasts for more than 24 hours then alternates with a nonfebrile stage of 24 hours or more. A patient is admitted to the hospital with high fever. The healthcare provider tells the nurse to administer a drug to decrease heat production in the patient. Which drug will most likely be prescribed to this patient? 1 Salicylates 2 Indomethacin 3 Corticosteroids 4 Acetaminophen - 3 Corticosteroids reduce heat production by interfering with the immune system. As a result, they bring down the temperature of the patient. Salicylates, indomethacin, and acetaminophen reduce the body temperature by promoting heat loss from the body. The nurse in the pediatric intensive care unit is evaluating the vital signs of an infant born to an HIV-positive mother. The infant's temperature was high in previous readings. The blood reports of the infant are pending. What are the possible sites where temperature can be measured in this patient? Select all that apply. 1 Oral site 2 Rectal site 3 Axillary site 4 Temporal artery site 5 Tympanic membrane site - 4, 5 Various sites can be used to measure temperature in infants. In this case, the infant could be HIV positive so it is important to use sites where there is a low risk of exposure to body fluids for the nurse. There is a risk of exposure to body fluids in both oral and rectal sites, so these are not appropriate in this case. The tympanic membrane site can be used in this case because there is low risk of exposure to body fluids; there is also reduced infant handling and heat loss because measuring from the tympanic membrane site is a very rapid measurement (2 to 5 seconds). There is no risk of injury to the patient or nurse when measuring from the temporal artery site, so there is no risk of exposure to body fluids. The axillary site is not recommended for measuring temperature in infants and young children. A healthcare provider instructs the nurse to measure the body temperature of a patient. Which sites does the nurse choose to measure body temperature? Select all that apply. 1 Ulnar artery 2 Temporal artery 3 Pulmonary artery 4 Dorsalis pedis artery 5 Tympanic membrane - 2, 3, 5 Core and surface body temperature can be measured at several sites. Intensive care units use the core temperatures of the pulmonary artery, esophagus, and urinary bladder. These measurements require the use of continuous invasive devices placed in body cavities or organs and continually display readings on an electronic monitor. Intermittent temperature measurements are obtained from the mouth, rectum, tympanic membrane, temporal artery, and axilla. The ulnar artery and dorsalis pedis artery are usually not employed for measuring the body temperature in a patient. These arteries are palpated to check for the pulse. The nurse is giving a tepid sponge bath to a patient. The patient suddenly starts shivering during the bath. How does the nurse manage the shivering of the patient? Select all that apply. 1 Use cooling fans. 2 Administer meperidine or butorphanol. 3 Have patient bathe with alcohol-water solutions. 4 Wrap the patient's extremities. 5 Apply ice packs to axillae and groin areas. - 2, 4 Meperidine and butorphanol are medications that reduce shivering. Wrapping the patient's extremities provides warmth and reduces shivering. The use of cooling fans, bathing with alcohol-water solutions, and placing of ice packs on the axillae and groin areas will take heat away from the body and increase the shivering. On examination, the nurse finds that the patient's body temperature is high. What are the situations when the body temperature rises above the baseline? Select all that apply. 1 After long-distance running 2 After taking a stroll in the park 3 During physical or emotional stress 4 During the evening, maximum at 4:00 pm 5 During early morning from 1:00 am to 4:00 am - 1, 3, 4 The body maintains a balance between heat production and heat loss. This is reflected by various temperature readings throughout the day. Exercise such as long-distance running, stress, and strong emotions can increase cellular activity, thus raising body temperature. Body temperature may increase as high as 1 degree Fahrenheit because of an increase in physical activity throughout the day and is at its peak at 4.00 pm; thereafter it decreases. Taking a stroll in the park does not raise body temperature because it does not cause physical exertion. For most people, body temperature is usually lowest in the morning because of a decrease in the basal metabolic rate related to inactivity during the night. A patient has a body temperature of 99° F. What temperature does the nurse record in Celsius? Record your answer using a whole number. ___° C - 37 To convert Fahrenheit to Celsius, the Fahrenheit reading should be subtracted by 32, and then the result should be multiplied by 5/9. Applying this formula to 99° F, we get (99 - 32) × 5/9 = 37. Or (99 - 32) / 1.8 = 37 A patient presents to an emergency room with a high body temperature. Which nursing measures does the nurse implement to reduce the patient's body temperature? Select all that apply. 1 Switch on a fan. 2 Apply an ice pack. 3 Apply an aquathermia pad. 4 Bathe the patient with a cool cloth. 5 Cover the body with dark and closely woven clothes. - 1, 2, 4 A fan promotes the loss of heat through convection. Heat loss through conduction can be encouraged by the application of ice packs and bathing the patient with a cool cloth. Aquathermia pads help the body gain heat through conduction; they do not promote heat loss. Covering the body with dark and closely woven clothes reduces heat lost from radiation; the clothes will not decrease the patient's body temperature. The nurse notes that the patient has been experiencing febrile episodes lasting more than 24 hours interrupted by periods of normal body temperature that also last than 24 hours. What does the nurse infer about the patient's fever pattern? 1 Sustained fever 2 Relapsing fever 3 Remittent fever 4 Intermittent fever - 2 When a patient shows periods of febrile episodes alternating with acceptable normal body temperatures, with both often lasting longer than 24 hours, it is called relapsing fever. Sustained fever is the body temperature that is constant, with a little fluctuation. When fever spikes and falls without returning to normal temperature, it is called remittent fever. Intermittent fever is associated with spikes interspersed with a return to normal temperature levels at least once within 24 hours. The nurse is assessing a patient who has just been rescued after falling into a frozen lake. The patient's body temperature has fallen below 93.2° F (34° C). Which signs should the nurse expect the patient to show? Select all that apply. 1 Cyanosed skin 2 Uncontrolled shivering 3 Cardiac dysrhythmias 4 Increased blood pressure 5 Increased respiratory rate - 1, 2, 3 This is a typical case of accidental hypothermia in which the patient shows signs such as uncontrolled shivering and cyanosis; cardiac dysrhythmias may occur in later stages. The body may try to generate heat to counteract hypothermia by shivering. Hypothermia results in a decreased blood supply to the peripheral organs, resulting in cyanosis. Cardiac dysrhythmias may occur because the cells of the body cannot function at low temperatures. Blood pressure and respiratory rate tend to fall in hypothermia. Which patients are most at risk for tachypnea? Select all that apply. 1 A patient just admitted with four rib fractures 2 A woman who is 9 months pregnant 3 An adult who has consumed alcoholic beverages 4 An adolescent awaking from sleep 5 A patient who regularly runs marathons - 1, 2 Rib fractures would cause splinting and pain that increase respiratory rate. Pregnancy impedes diaphragmatic excursion, causing shallow, frequent breaths. Which alteration in the body is prominent when there is a rise in body temperature? 1 Decreased respiratory rate 2 Decreased body metabolism 3 Decreased oxygen consumption 4 Decreased concentration of iron in the blood - 4 Increased temperature reduces the concentration of iron in the blood plasma, suppressing the growth of bacteria. Heart and respiratory rates increase to meet the metabolic needs of the body during fever conditions. Body metabolism increases 10 percent for every degree (Celsius) of temperature elevation. When there is a rise in temperature, cellular metabolism increases, thereby increasing the oxygen consumption. The registered nurse is teaching a nursing student about interventions that should be performed for patients with fever to minimize heat production. Which interventions performed by the nursing student reflect effective learning? Select all that apply. 1 Providing 8 to 10 glasses of fluids per day 2 Applying a damp cloth to the patient's forehead 3 Encouraging the patient to increase rest periods 4 Reducing external covering on the patient's body 5 Advising the patient to avoid turning and ambulating excessively - 3, 5 Nursing interventions are important for patients who have fever. Excessive activity such as turning and ambulation increases oxygen demands and heat production; therefore, the nurse should advise the patient to limit such activities and increase rest periods. Providing 8 to 10 glasses of fluids is a safety requirement for increased metabolic rate. Reducing external covering on the patient would help maximize heat loss from the body. Application of a damp cloth to the patient's forehead promotes comfort but does not minimize heat production. Which factor is associated with a 0.5 to 1° C change in body temperature during a 24-hour period? 1 Stress 2 Exercise 3 Hormonal level 4 Circadian rhythm - 4 Temperature is one of the most stable rhythms in humans. Circadian body temperature rhythm normally changes 0.5 to 1° C (0.9 to 1.8° F) during a 24-hour period. Physical and emotional stress increases body temperature through hormonal and neural stimulation, but these stressors are not associated with a 0.5 to 1° C change in body temperature during a 24-hour period. Prolonged strenuous exercise, such as long-distance running, temporarily raises body temperature. Hormonal variations during the menstrual cycle cause body temperature fluctuations. Woman who have stopped menstruating often experience periods of hot flashes, in which skin temperature increases up to 4° C (7.2° F). You observe a nursing student taking a blood pressure (BP) reading on a patient. The patient's BP range over the past 24 hours was 132/64 to 126/72 mm Hg. The student used a BP cuff that was too narrow for the patient. Which BP reading made by the student is most likely caused by the incorrect choice of BP cuff? 1 96/40 mm Hg 2 110/66 mm Hg 3 130/70 mm Hg 4 156/82 mm Hg - 4 When you use a blood pressure cuff that is too narrow or short, your patient will most likely have a BP reading that is higher than it really is: You will get a falsehigh reading. If the bladder or cuff were too wide, the reading would be a false-low reading. The nurse is attending to a patient with fever. Which nursing interventions are appropriate when caring for this patient? Select all that apply. 1 Provide fluids. 2 Administer routine antibiotics. 3 Instruct patient to limit physical activity. 4 Set the room temperature between 86° F (30° C) and 93° F (34° C). 5 Reduce the external covering of the patient's body enough so that the heat dissipates but not so much that the patient begins to shiver. - 1, 3, 5 Adequate fluids should be provided to compensate for the fluid loss due to sweating and hypermetabolism. Physical activities would further increase core body temperature; therefore, they should be avoided to minimize heat production. Reducing the external covering of the patient's body would help to dissipate heat and decrease body temperature. Antibiotics should not be administered unless the causative pyrogen has been identified. The room temperature should be set at a lower, comfortable temperature of around 70° F (21° C) to 80° F (27° C). While caring for a patient with a respiratory disorder, which abnormality can be most appropriately interpreted by the primary health care provider from the continuous recordings of the capnogram? 1 Changes in heart rate 2 Changes in ventilation 3 Changes in heart rhythm 4 Changes in partial pressures of oxygen - 2 Capnography is the measurement of exhaled carbon dioxide throughout exhalation. Interpretation of a continuous recording, or capnogram, can detect changes in ventilation. The ETCO2 value can be used to evaluate respiratory and cardiac status. Electrocardiogram interpretation is most appropriate for interpreting changes in heart rate and rhythm. Capnography approximates the partial pressure of carbon dioxide, but may not determine the changes in the partial pressure of oxygen. A patient has a family history of hypertension. What education is helpful in reducing the risk of hypertension in the patient? Select all that apply. 1 Discouraging smoking 2 Encouraging a diet completely without salt 3 Discouraging heavy alcohol intake 4 Discouraging a sedentary lifestyle 5 Starting prophylactic antihypertensive medication - 1, 3, 4 The recommendations for a patient with a family history of hypertension include discouraging smoking and heavy drinking. Smoking and heavy drinking promote atherosclerosis. A sedentary lifestyle increases the risk of hypertension; discouraging a sedentary lifestyle helps to reduce obesity and the risk of hypertension. A certain amount of salt is required for physiological function, so only a high-sodium diet should be discouraged. The patient is genetically predisposed to having hypertension in the future, but the patient does not have hypertension now. Lifestyle and diet modifications may be sufficient to prevent the occurrence of hypertension in this patient; the patient need not use antihypertensives for prophylaxis.