Foundations Of Nursing 7th Edition By Kim Cooper Kelly Gosnell – Test Bank

Chapter 11: Vital Signs
Cooper and Gosnell: Foundations of Nursing, 7th Edition

MULTIPLE CHOICE

1. What part of the body maintains a balance between heat production and heat loss, regulating body temperature?
a. Thymus
b. Thyroid
c. Hypothalamus
d. Adrenal glands

ANS: C
Body temperature is regulated by the hypothalamus.

DIF: Cognitive Level: Knowledge REF: Page 61 OBJ: 9| 13
TOP: Vital signs KEY: Nursing Process Step: N/A MSC: NCLEX: N/A

2. What type of body temperature remains relatively constant?
a. Surface
b. Rectal
c. Oral
d. Core

ANS: D
The core body temperature remains relatively constant.

DIF: Cognitive Level: Knowledge REF: Page OBJ: 2
TOP: Vital signs KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity

3. The nurse uses cooling techniques to keep the body temperature below 105° F. What can result from an elevated temperature?
a. Excessive thirst
b. Excessive perspiration
c. Damage to body cells
d. Increased heart rate

ANS: C
If the temperature exceeds 105° F, normal body cells may be damaged.

DIF: Cognitive Level: Comprehension REF: Page OBJ: 8
TOP: Vital signs KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity

4. The emergency department nurse quickly assesses the temperature of an unconscious patient who has been outside all night in below-freezing temperatures. What temperature is the nurse aware of that can lead to death?
a. 95.2° F
b. 93.0° F
c. 93.2° F
d. 90.8° F

ANS: C
Death can occur if the temperature falls below 93.2° F.

DIF: Cognitive Level: Comprehension REF: Page OBJ: 9
TOP: Vital signs KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity

5. What is the term for a fever that rises and falls but does not return to normal until the patient is well?
a. Constant
b. Intermittent
c. Remittent
d. Elevated

ANS: C
A remittent fever does not return to normal until the patient becomes well.

DIF: Cognitive Level: Knowledge REF: Page 62 OBJ: 9
TOP: Remittent fever KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity

6. How should the nurse position the ear pinna when using the tympanic thermometer on a child?
a. Upward and back
b. Parallel
c. Downward and back
d. Upward and forward

ANS: C
Using the tympanic thermometer for a child, the nurse will tug the ear pinna down and back.

DIF: Cognitive Level: Application REF: Page 67, Skill 4-1
OBJ: 3| 9 TOP: Tympanic thermometer for a child
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity

7. How should the nurse position the earpieces on a stethoscope to ensure optimum reception?
a. Backward
b. Parallel to the ears
c. Toward the face
d. Downward

ANS: C
To ensure the best reception of sound, place earpieces pointing toward the face.

DIF: Cognitive Level: Application REF: Page OBJ: 9| 12
TOP: Vital signs KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity

8. What does the nurse use the diaphragm of the stethoscope to best assess?
a. Carotid sounds
b. Lung sounds
c. Vascular sounds
d. Low-pitched sounds

ANS: B
Lung sounds are auscultated by using the diaphragm of the stethoscope.

DIF: Cognitive Level: Comprehension REF: Page OBJ: 6| 9
TOP: Stethoscope use KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity

9. What is the pulse—the expansion and contraction of an artery— produced by?
a. Contraction of the right atrium
b. Contraction of the right ventricle
c. Contraction of the left atrium
d. Contraction of the left ventricle

ANS: D
Expansion and contraction of an artery is caused by the ejection of blood from the left ventricle.

DIF: Cognitive Level: Knowledge REF: Page 70 OBJ: 4
TOP: Vital signs KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity

10. When assessing vital signs on a 40-year-old male, the nurse identifies a pulse rate of 120. What is this pulse interpreted as by the nurse?
a. Normal
b. Bradycardic
c. Arrhythmic
d. Tachycardic

ANS: D
If the pulse is faster than 100 bpm on an adult patient, it is considered to be tachycardic.

DIF: Cognitive Level: Analysis REF: Page OBJ: 5
TOP: Tachycardia KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity