Ch.5 Vital Signs & Circulation Status Complete Test Bank

Chapter 5: Assessing Physiological Status: Vital Signs and Peripheral Circulation

Multiple Choice

1. Which of the following would be MOST appropriate to include in an initial evaluation of a 75-year-old woman recently discharged from a rehabilitation facility for a hip fracture being seen in her home?
   1. Blood pressure
   2. Lung sounds
   3. Pedal pulses
   4. Weight
2. A 39-year-old man who had knee surgery 4 weeks ago is ready to begin aerobic conditioning activities. What is the estimated maximum heart rate for this patient?
   1. 165 beats per minute
   2. 181 beats per minute
   3. 197 beats per minute
   4. 216 beats per minute
3. A 51-year-old patient who had a myocardial infarction 5 weeks ago is ready to begin outpatient cardiac rehabilitation. If the patient’s resting heart rate is 78 beats per minute, which of the following values should be used as a target heart rate for conditioning activities for this patient?
   1. 92 beats per minute
   2. 98 beats per minute
   3. 108 beats per minute
   4. 114 beats per minute
4. Which of the following techniques should be used to assess a patient’s carotid pulse?
   1. Palpate one artery with a light, circular massaging motion during assessment.
   2. Palpate both arteries simultaneously for accurate comparison.
   3. Stand on the opposite side of the artery you are assessing.
   4. Use two fingers to palpate just to the side of the larynx.
5. Which of the following methods is MOST appropriate for assessing a patient’s pulse during an initial evaluation?
   1. Count the pulse for 10 seconds and multiply by 6.
   2. Count the pulse for 15 seconds and multiply by 4.
   3. Count the pulse for 20 seconds and multiply by 3.
   4. Count the pulse for 60 seconds.
6. Which of the following is true regarding blood pressure?
   1. It is the range of pressure exerted by the blood in the ventricles.
   2. The difference between systolic and diastolic pressures is pulse pressure.
   3. Blood pressure is affected by blood volume and vessel compliance, not by vessel size.
   4. Values are affected only by pathological conditions.
7. Which of the following blood pressure values indicates that the patient’s exercises should be stopped immediately?
   1. A diastolic reading greater than 115 mm Hg
   2. A 5 mm Hg drop from baseline in the systolic pressure
   3. A failure of the diastolic pressure to increase with increasing workload
   4. A systolic reading greater than 180 mm Hg
8. Which of the following is an important aspect of accurate home blood pressure monitoring?
   1. Take at least two readings no more than 30 seconds apart to get an accurate average.
   2. Take the blood pressure at the same time every day.
   3. Take the blood pressure only in the right arm.
   4. Use a cuff with a width-to-length ratio of 2:1.
9. Which of the following actions is MOST likely to result in the inability to detect Korotkoff sounds accurately during blood pressure assessment?
   1. The cuff is deflated fully before a second attempt.
   2. The cuff is not inflated enough.
   3. The cuff is overinflated.
   4. The valve is opened too slowly.
10. Which of the following is true regarding the use of automated blood pressure monitors?
    1. Cuff placement is more critical with the use of automated units than for auscultated measurement.
    2. Finger units are the most accurate method of automated home blood pressure monitoring.
    3. The arm should be placed in the same position as it is during auscultated measurement.
    4. Automated monitors are generally less sensitive to changes in body movements.
11. Which of the following is the best method for assessing respiration in a patient who had a stroke 6 days ago?
    1. Ask the patient to refrain from talking so that you can count the patient’s breathing rate.
    2. Assess respiration during the patient’s conversation so that the patient is unaware.
    3. Check the nursing records to determine the patient’s respiration rate.
    4. Count the rise and fall of the chest for 30 seconds while the patient is unaware.
12. In addition to heart rate and blood pressure, which vital sign measurement would generally be the MOST meaningful for a patient with chronic obstructive pulmonary disease?
    1. Pedal pulse
    2. Urinary output
    3. Respiration
    4. Temperature
13. Which of the following assessment sites typically yields a temperature reading closest to a patient’s core temperature?
    1. Axilla
    2. Ear
    3. Mouth
    4. Rectum
14. You are working with a man who had a bout of congestive heart failure. He is now quite deconditioned and is receiving 2 L of oxygen per minute through a nasal cannula. You are about to begin ambulation with this patient. Which of the following would be true in this clinical scenario?
    1. Maximum oxygen saturation for this patient should be 95%.
    2. Use of a fingertip pulse oximeter replaces the need to measure other physiological responses.
    3. You will be concerned if the patient’s oxygen saturation drops below 90%.
    4. Monitoring oxygen saturation is not necessary while the patient is receiving supplemental oxygen.
15. Which of the following is true regarding pain assessment in patient care?
    1. Pain assessment is an objective measurement of the patient’s experience.
    2. Pain assessment is rarely useful in determining the underlying source of the pain.
    3. Responses to pain are similar across all social and cultural groups.
    4. Pain is always abnormal and can be a valuable indicator of a serious problem.