Chapter 06: Vital Signs and Pain Assessment

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 as 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: a. pain be assessed on all discharges. b. repeated assessment of pain be limited to those patients who complain of pain. c. repeated intensity documentation be made of the course of pain relief for all patients. d. pain be assessed on surgical patients.

ANS: C

TJC requires pain assessment on all admissions, repeated assessments for pain regardless of the initial complaint or surgical experience, and repeated intensity documentation of the course of pain relief for all patients.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

5. The perception of pain: a. is the same across cultures. b. can be easily assessed in neonates. c. is predictable with the same circumstances. d. is affected by emotions and quality of sleep.

ANS: D

The perception of pain is variable and is affected by emotions, cultural background, sleep deprivation, previous pain experience, and age. Perception of pain is different among different cultures. Neonates do feel pain, but perception of pain cannot be assessed in neonates. Each circumstance will provide different pain perception.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

6. The most frequent cause of serious hypertension in children is: a. heart disease. b. liver failure. c. renal disease. d. rheumatic fever.

ANS: C

If the systolic blood pressure is elevated and the diastolic blood pressure is not, anxiety may be responsible. Blood pressure in children varies by gender and height at any age.

Hypertension in children is becoming more common because of the increased prevalence of overweight children. Usually, hypertension is caused by kidney disease, renal arterial disease, coarctation of the aorta, and pheochromocytoma, not heart disease, liver failure, or rheumatic fever.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Reduction of Risk Potential

7. Unde e ima ion of blood p e e ill occ if he c ff id h co e : a. less than half of the upper arm. b. less than 5 inches of the lower arm. c. more than two-thirds of the upper arm. d. more than 4 inches of the lower arm.

ANS: C

Cuffs that are too wide will underestimate blood pressure, which would occur with a cuff that covers more than two-thirds of the upper arm.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. Bounding pulse rate b. Regular pulse rate c. Sustained high pulse rate d. Intermittent slow pulse rate

8. Which pulse characteristic in the neonate may indicate infection?

ANS: C

Sustained tachycardia in a neonate may be the first indication of infection.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. Slower respiratory rate b. Faster respiratory rate c. Shallower respirations d. Deeper respirations

9. Infants delivered by Cesarean section demonstrate which respiratory characteristic in comparison to infants delivered vaginally?

ANS: B

Infants delivered by Cesarean section may have a more rapid respiratory rate than babies delivered vaginally.

DIF: Cognitive Level: Understanding (Comprehension)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation

Multiple Response

1. Which occurs with malignant hypertension? (Select all that apply.)

a. Blurred vision b. Sleep disturbance c. Tachycardia d. Dyspnea e. Encephalopathy

ANS: A, D, E

Signs of malignant hypertension include headache, blurred vision, dyspnea, and encephalopathy.

DIF: Cognitive Level: Analyzing (Analysis)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation a. Allodynia b. Sleep disturbance c. Blood flow changes d. Numbness e. Edema

2. In a syndrome in which regional pain extends beyond this specific peripheral nerve injury, you would notice which of the following? (Select all that apply.)

ANS: A, C, D, E

Complex regional pain syndrome includes the following symptoms: burning shooting pain with aching character, exaggerated sensitivity to cold, allodynia, numbness, edema, blood flow changes, and temperature changes.

DIF: Cognitive Level: Analyzing (Analysis)

OBJ: Nursing process assessment MSC: Physiologic Integrity: Physiologic Adaptation