NUR 230 Exam 3 (Latest ): The
Childbearing / Child Caring Family
Which temperature, taken rectally, is outside the normal range for a healthy adult? -
ANSWER 97 degrees fahrenheit (below normal range for healthy adult)
An increase in body temperature may be an indication of which condition? -
ANSWER infection, damage to hypothalamus, and vasoconstriction
vasodilation - ANSWER dilation of blood vessels, increasing heat loss through the
skin; it is not related to temperature regulation
hypothermia - ANSWER describes the condition of having abnormally low body
temperature and is not a temperature-regulating reaction
pyrexia - ANSWER fever response, triggered by the production and release of
prostaglandins; not related to temperature regulation
shivering - ANSWER results from contraction and relaxation of the skeletal
muscles, warming the body
Which is the best method by which to measure temperature in a 5-month-old patient
- ANSWER tympanic method
what describes the benefit to using an electric thermometer to measure an adult
patient's temperature - ANSWER quicker to use
which method of temperature measurement is the most reliable - ANSWER
tympanic because it measures core temperature
The nurse is taking the pulse of an adult patient. which description of pulse
amplitude is characteristic of a normal pulse - ANSWER strong
which findings relating to a patient's pulse are considered normal - ANSWER
regular rhythm, strong amplitude, contour with smooth uptake
which characteristics of respiration are normal findings - ANSWER breathing
without effort, breathing with regular rhythm, abdominal movement with breathing,
quiet breathing
the best way to measure respirations is to count the breathe for ____ seconds and
multiply by 2 - ANSWER 30
which respiratory rate (in breaths per minute) would the nurse characterize as
bradypnea - ANSWER 9
which blood pressure response is expected when a patient rises from a sitting
position - ANSWER a rise in diastolic pressure
, blood pressure follows a diurnal pattern, peaking at what time during the day -
ANSWER midmorning
what auscultatory landmark, identified after the systolic sound, marks the first
diastolic sound - ANSWER muffling of sounds
what auscultatory landmark marks the first systolic sound - ANSWER two
consecutive beats
What marks the auscultatory gap - ANSWER disappearance of the korotkoff
sounds
What is the appropriate rate to deflate a BP cuff - ANSWER 2-3 mmHg per second
The pulse oximeter measures a patient's blood oxygen based on which properties of
hemoglobin? - ANSWER deoxygenated hemoglobin absorbs more red light than
oxygenated hemoglobin
Which body areas are best for measuring the blood levels of an adult patient -
ANSWER finger, toe, pinna
the pulse oximetry reading indicates which physiological measure - ANSWER how
much oxygen the blood is carrying
What is one limitation to most self-reporting pain scales relating to the patient's
perception of pain - ANSWER very few include patient's emotional response
numeric pain scale - ANSWER numbers with which the patient can rate their pain
descriptive pain scale - ANSWER pain descriptions with which the patient can rate
their
behavioral pain scale - ANSWER allows the nurse to choose from pain behaviors to
rate the pain of the patient and is not a self-reporting pain scale
When assessing a patient's pain, the nurse should remember that which actions may
increase the pain felt - ANSWER moving, coughing, and deep breathing
the nurse is examining a patient and identifies a facial mask of pain. What features
characterize this expression? - ANSWER lackluster eyes, wrinkled forehead, and
grimace
Which patient behaviors are associated with pain - ANSWER guarding, head
rocking, and scattered movement
Which body movements may indicate pain in a patient - ANSWER rubbing, pacing,
inability to keep hands still
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