CHAPTER 06: VITAL SIGNS AND PAIN ASSESSMENT

C HAPTER 06: V ITAL S IGNS AND P AIN
A SSESSMENT
Ball: Seidel’s Guide to Physical Examination, 9th Edition



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 a s 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: