Chapter 11: Vital Signs
Fundamental Nursing Skills and Concepts 12th Edition, Timby
MULTIPLE CHOICE
1. Because the elderly have non-elastic blood vessels, they are prone to orthostatic
hypotension. A priority intervention for a patient with orthostatic hypotension is to:
a. keep the patient in bed in a high Fowlers position.
b. allow the patient to sit on the side of the bed for a minute before standing.
c. instruct the patient to use the wheelchair for all mobility activity.
d. help the patient to rise quickly and support the patient for a minute.
ANS: B
The elderly often experience orthostatic hypotension and are at risk for falls and
should be encouraged to sit on the side of the bed a minute before standing. These
patients also benefit from the use of elastic stockings.
DIF: Cognitive Level: Application REF: d. 361, Elder Care OBJ:
Theory #2 TOP: Orthostatic Hypotension KEY: Nursing Process
Step: Planning MSC: NCLEX: Safe Effective Care
Environment: safety and infection control
2. An elderly patient has a tympanic temperature of 96.2 F (35.7 C). What nursing
intervention would best meet this patients need?
a. Take the patients vital signs every 4 hours, including temperature.
b. Provide fluids to increase circulation.
c. Increase room temperature to 72 F (22.2 C) and add blankets to the bed.
d. Check the temperature orally to confirm the accuracy of the reading.
ANS: C
Nursing interventions for treating hypothermia should focus on reducing heat loss and
supplying additional warmth, such as increasing the room temperature and adding
blankets to the bed.
DIF: Cognitive Level: Application REF: d. 341 OBJ: Theory #3
TOP: Vital Signs: Temperature KEY: Nursing Process
Step: Implementation MSC: NCLEX: Physiological Integrity:
basic care and comfort
3. The nurse using either a regular or an electronic sphygmomanometer would ensure that
the cuff is the correct size by:
a. using a narrow cuff for an obese patient.
b. making sure the width of the bladder is at least 3 inches.
c. confirming that the bladder goes around three fourths of the arm.
d. always using a wide cuff.
ANS: C
For accuracy in a BP reading, the cuff of the sphygmomanometer should have a
bladder that goes around three fourths of the arm.
DIF: Cognitive Level: Comprehension REF: d 358, Skill 21-6
OBJ: Clinical Practice #4 TOP: Vital Signs: Blood Pressure
, KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity: basic care and comfort
4. For the nurse to assess the most accurate respiration count, the nurse should:
a. inform the patient about his respirations and ask him to breathe normally.
b. count each inhalation and expiration for 1 full minute.
c. watch the patients chest rise and fall from a distance.
d. continue to hold the patients radial pulse, and count the respirations for 30 seconds
and multiply them
ANS: D
The respirations should be counted for 30 seconds and multiplied by 2 if they are
regular. If the patient knows the nurse is assessing the respiration, he or she may alter
breathing.
DIF: Cognitive Level: Application REF: d 350, Skill 21-5 OBJ:
Clinical Practice #3 TOP: Vital Signs: Respirations KEY: Nursing
Process Step: Assessment MSC: NCLEX: Physiological Integrity:
basic care and comfort
5. Elderly patients with hypertension may have an auscultatory gap in their Korotkoff
sounds. Itis important when taking their blood pressure measurement to:
a. continue to listen until the cuff is deflated.
b. pump up the cuff until no sound is heard and then let the air out.
c. make sure the bell of the stethoscope is placed firmly over the artery.
d. stop midway and begin to inflate again.
ANS: A
Many older adults with hypertension have an auscultatory gap in their Korotkoff
sounds, making it important to listen until the cuff is deflated to avoid mistaking the
auscultatory gap as the Korotkoff sound.
DIF: Cognitive Level: Application REF: d 360 OBJ: Theory #6
TOP: Vital Signs in the Elderly KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological Integrity: basic
care and comfort
6. Regarding the blood pressure in children, the diastolic pressure is assessed by the
auscultation of a:
a. clear tapping that gradually grows louder.
b. murmur or swishing sound that increases with depression of the cuff.
c. sudden change or muffling of the sound.
d. louder knocking sound that occurs with each heartbeat.
ANS: C
A sudden change or muffling sound (Phase IV) indicates the diastolic pressure in
children and in some adults.
DIF: Cognitive Level: Application REF: d 360 OBJ: Clinical Practice #4
TOP: Vital Signs in Children KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological Integrity: basic
care and comfort
Fundamental Nursing Skills and Concepts 12th Edition, Timby
MULTIPLE CHOICE
1. Because the elderly have non-elastic blood vessels, they are prone to orthostatic
hypotension. A priority intervention for a patient with orthostatic hypotension is to:
a. keep the patient in bed in a high Fowlers position.
b. allow the patient to sit on the side of the bed for a minute before standing.
c. instruct the patient to use the wheelchair for all mobility activity.
d. help the patient to rise quickly and support the patient for a minute.
ANS: B
The elderly often experience orthostatic hypotension and are at risk for falls and
should be encouraged to sit on the side of the bed a minute before standing. These
patients also benefit from the use of elastic stockings.
DIF: Cognitive Level: Application REF: d. 361, Elder Care OBJ:
Theory #2 TOP: Orthostatic Hypotension KEY: Nursing Process
Step: Planning MSC: NCLEX: Safe Effective Care
Environment: safety and infection control
2. An elderly patient has a tympanic temperature of 96.2 F (35.7 C). What nursing
intervention would best meet this patients need?
a. Take the patients vital signs every 4 hours, including temperature.
b. Provide fluids to increase circulation.
c. Increase room temperature to 72 F (22.2 C) and add blankets to the bed.
d. Check the temperature orally to confirm the accuracy of the reading.
ANS: C
Nursing interventions for treating hypothermia should focus on reducing heat loss and
supplying additional warmth, such as increasing the room temperature and adding
blankets to the bed.
DIF: Cognitive Level: Application REF: d. 341 OBJ: Theory #3
TOP: Vital Signs: Temperature KEY: Nursing Process
Step: Implementation MSC: NCLEX: Physiological Integrity:
basic care and comfort
3. The nurse using either a regular or an electronic sphygmomanometer would ensure that
the cuff is the correct size by:
a. using a narrow cuff for an obese patient.
b. making sure the width of the bladder is at least 3 inches.
c. confirming that the bladder goes around three fourths of the arm.
d. always using a wide cuff.
ANS: C
For accuracy in a BP reading, the cuff of the sphygmomanometer should have a
bladder that goes around three fourths of the arm.
DIF: Cognitive Level: Comprehension REF: d 358, Skill 21-6
OBJ: Clinical Practice #4 TOP: Vital Signs: Blood Pressure
, KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity: basic care and comfort
4. For the nurse to assess the most accurate respiration count, the nurse should:
a. inform the patient about his respirations and ask him to breathe normally.
b. count each inhalation and expiration for 1 full minute.
c. watch the patients chest rise and fall from a distance.
d. continue to hold the patients radial pulse, and count the respirations for 30 seconds
and multiply them
ANS: D
The respirations should be counted for 30 seconds and multiplied by 2 if they are
regular. If the patient knows the nurse is assessing the respiration, he or she may alter
breathing.
DIF: Cognitive Level: Application REF: d 350, Skill 21-5 OBJ:
Clinical Practice #3 TOP: Vital Signs: Respirations KEY: Nursing
Process Step: Assessment MSC: NCLEX: Physiological Integrity:
basic care and comfort
5. Elderly patients with hypertension may have an auscultatory gap in their Korotkoff
sounds. Itis important when taking their blood pressure measurement to:
a. continue to listen until the cuff is deflated.
b. pump up the cuff until no sound is heard and then let the air out.
c. make sure the bell of the stethoscope is placed firmly over the artery.
d. stop midway and begin to inflate again.
ANS: A
Many older adults with hypertension have an auscultatory gap in their Korotkoff
sounds, making it important to listen until the cuff is deflated to avoid mistaking the
auscultatory gap as the Korotkoff sound.
DIF: Cognitive Level: Application REF: d 360 OBJ: Theory #6
TOP: Vital Signs in the Elderly KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological Integrity: basic
care and comfort
6. Regarding the blood pressure in children, the diastolic pressure is assessed by the
auscultation of a:
a. clear tapping that gradually grows louder.
b. murmur or swishing sound that increases with depression of the cuff.
c. sudden change or muffling of the sound.
d. louder knocking sound that occurs with each heartbeat.
ANS: C
A sudden change or muffling sound (Phase IV) indicates the diastolic pressure in
children and in some adults.
DIF: Cognitive Level: Application REF: d 360 OBJ: Clinical Practice #4
TOP: Vital Signs in Children KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological Integrity: basic
care and comfort
