Chapter 30: Vital Signs

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Chapter 30: Vital Signs

Potter et al: Canadian Fundamentals of Nursing, 6th Edition

MULTIPLE CHOICE

• How does the posterior hypothalamus help control temperature?
• By causing vasoconstriction.
• By shunting blood to the skin and extremities.
• By increasing sweat production.
• By causing vasodilation.

ANS: A

If the posterior hypothalamus senses that the body’s temperature is lower than the set point, the body initiates heat conservation mechanisms. Vasoconstriction of blood vessels reduces blood flow to the skin and extremities. The anterior hypothalamus controls heat loss by inducing sweating, vasodilation of blood vessels, and inhibition of heat production.

DIF: Remember REF: 528 OBJ: Explain the physiology of normal regulation of blood pressure, pulse, oxygen saturation, and respirations. TOP: Assessment MSC: NCLEX: Physiological Integrity

• Of the following mechanisms of heat loss by the body, identify the mechanism that transfers

heat away by using air movement?

• Radiation.
• Conduction.
• Convection.
• Evaporation.

ANS: C

Convection is the transfer of heat away from the body by air movement. Conduction is the transfer of heat from one object to another with direct contact. Radiation is the transfer of heat from the surface of one object to the surface of another without direct contact between the two. Evaporation is the transfer of heat energy when a liquid is changed to a gas.

DIF: Understand REF: 529 OBJ: Explain the physiology of normal regulation of blood pressure, pulse, oxygen saturation, and respirations. TOP: Assessment MSC: NCLEX: Physiological Integrity

• The patient has a temperature of 40.7°C (105.2°F). The nurse is attempting to lower his

temperature by providing tepid sponge baths and placing cool compresses in strategic body locations. The nurse is attempting to lower the patient’s temperature through the use of which of the following?

• Radiation.
• Conduction.
• Convection.
• Evaporation.

ANS: B

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Applying an ice pack or bathing a patient with a cool cloth increases conductive heat loss.Radiation is the transfer of heat from the surface of one object to the surface of another without direct contact between the two. Evaporation is the transfer of heat energy when a liquid is changed to a gas. Convection is the transfer of heat away from the body by air movement.

DIF: Apply REF: 529 OBJ: Explain the physiology of normal regulation of blood pressure, pulse, oxygen saturation, and

respirations. TOP: Implementation

MSC: NCLEX: Physiological Integrity

• When focusing on temperature regulation of newborns and infants, what should the nurse

know?

• Temperatures are basically the same for infants and older persons.
• Infants have well-developed temperature-regulating mechanisms.
• The normal temperature range gradually increases as the person ages.
• Newborns need to wear a cap to prevent heat loss.

ANS: D

A newborn loses up to 30% of body heat through the head and therefore needs to wear a cap to prevent heat loss. Temperature control mechanisms in newborns are immature and respond drastically to changes in the environment. The normal temperature range gradually drops with age.

DIF: Understand REF: 529 OBJ: Describe factors that cause variations in body temperature, pulse, oxygen saturation,

respirations, and blood pressure. TOP: Assessment

MSC: NCLEX: Physiological Integrity

• The nurse working the night shift on a surgical unit is making rounds at 0400 hours. She

notices that the patient’s temperature is 36°C (96.8°F), whereas at 1600 hours the preceding day, it was 37°C (98.6°F). What should the nurse do?

• Call the physician immediately to report a possible infection.
• Realize that this is a normal temperature variation.
• Provide another blanket to conserve body temperature.
• Provide medication to lower the temperature further.

ANS: B

Body temperature normally changes 0.5°C to 1°C (0.9°F to 1.8°F) during a 24-hour period.Unless the patient is complaining of being cold, there is no physiological need for providing an extra blanket or medication to lower the body temperature further. There is also no need to call a physician to report a normal temperature variation.

DIF: Apply REF: 530 OBJ: Describe factors that cause variations in body temperature, pulse, oxygen saturation,

respirations, and blood pressure. TOP: Implementation

MSC: NCLEX: Physiological Integrity

• The nurse is caring for a patient who has a temperature reading of 38°C (100.4°F). His last

two temperature readings were 37°C (98.6°F) and 36°C (96.8°F). The nurse should

• Call the physician and anticipate an order to treat the fever.
• Assume that the patient has an infection and order blood cultures.

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Canadian Fundamentals of Nursing 6th Edition Potter Test Bank

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• Wait an hour and recheck the patient’s temperature.
• Be aware that temperatures this high are harmful and affect patient safety.

ANS: C

Waiting an hour and rechecking the patient’s temperature would be the most appropriate action in this case. A fever usually is not harmful if it stays below 39°C (102.2°F), and a single temperature reading does not always indicate a fever. In addition to physical signs and symptoms of infection, a fever determination is based on several temperature readings at different times of the day in comparison with the usual value for that person at that time. Mild temperature elevations enhance the body’s immune system by stimulating white blood cell production. Staff nurses usually do not order blood cultures, and nurses should base actions on knowledge, not on assumptions.

DIF: Apply REF: 530 OBJ: Describe factors that cause variations in body temperature, pulse, oxygen saturation,

respirations, and blood pressure. TOP: Implementation

MSC: NCLEX: Physiological Integrity

• When heat loss mechanisms of the body are unable to keep pace with excess heat production,

the result is known as

• Pyrexia.
• The plateau phase.
• The set point.
• Becoming afebrile.

ANS: A

Pyrexia, or fever, occurs because heat loss mechanisms are unable to keep pace with excess heat production, which results in an abnormal rise in body temperature. The set point is the temperature point determined by the hypothalamus. When pyrogens trigger immune system responses, the hypothalamus reacts to raise the set point, and the body produces and conserves heat. During the plateau phase, chills subside and the person feels warm and dry as heat production and loss equilibrate at the new level. When the fever “breaks,” the patient becomes afebrile.

DIF: Remember REF: 530 OBJ: Identify ranges of acceptable vital sign values for an infant, a child, and an adult.TOP: Assessment MSC: NCLEX: Physiological Integrity

• The nurse is caring for a patient who has an elevated temperature. What should the nurse

know?

• Fever and hyperthermia are the same thing.
• Hyperthermia occurs when the body cannot reduce heat loss.
• Hyperthermia is an upward shift in the set point.
• Hyperthermia occurs when the body cannot reduce heat production.

ANS: D

Elevation in body temperature that is related to the body’s inability to promote heat loss or reduce heat production is hyperthermia. Fever and hyperthermia are not the same thing. Fever, not hyperthermia, is a shift in the set point.

DIF: Understand REF: 530| 531 OBJ: Describe factors that cause variations in body temperature, pulse, oxygen saturation,

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respirations, and blood pressure. TOP: Assessment

MSC: NCLEX: Physiological Integrity

• The patient is restless and has a temperature of 39°C (102.2°F). What is one of the first things

the nurse should do?

• Place the patient on oxygen.
• Restrict fluid intake.
• Increase patient activity.
• Increase patient’s metabolic rate.

ANS: A

During a fever, cellular metabolism increases, and oxygen consumption rises. Myocardial hypoxia produces angina. Cerebral hypoxia produces confusion. Interventions during a fever include oxygen therapy. Dehydration is a serious problem through increased respiration and diaphoresis, and a dehydrated patient is at risk for fluid volume deficit. Fluids should not be restricted. Increasing activity would increase the metabolic rate further, which would not be advisable.

DIF: Apply REF: 531 OBJ: Describe factors that cause variations in body temperature, pulse, oxygen saturation,

respirations, and blood pressure. TOP: Implementation

MSC: NCLEX: Physiological Integrity

• The patient needs temperatures measured every two hours. Which of the following cannot be

delegated to an unregulated care provider?

• Selecting appropriate route and device.
• Obtaining temperature measurement at ordered frequency.
• Being aware of the usual values for the patient.
• Assessing changes in body temperature.

ANS: D

The nurse is responsible for assessing changes in body temperature. The nurse instructs an unregulated care provider to select the appropriate route and device to measure temperature, to obtain temperature measurement at ordered frequency, and to be aware of the usual values for the patient.

DIF: Apply REF: 532 OBJ: Appropriately delegate vital sign measurement to unregulated care providers.TOP: Implementation MSC: NCLEX: Safe and Effective Care Environment

• The patient requires routine temperature assessment but is confused and easily agitated and

has a history of seizures. The nurse’s best option would be to take his temperature

• Orally.
• Tympanically.
• Rectally.
• By the axillary method.

ANS: B

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