Nokea
A nurse is caring for a group of patients. Which patient will the nurse see first?
- A. A crying infant with P-165 and R-54
- B. A sleeping toddler with P-88 and R-23
- C. A calm adolescent with P-95 and R-26
- D. An exercising adult with P-108 and R-24
Correct Answer: A
Rationale: An infant with pulse 165 and respirations 54 (A) is borderline high (normal 120-160, 30-60), plus crying suggests distress, warranting priority. Toddler (B), adolescent (C), and adult (D) values are normal for context. Choice A is correct, per triage prioritizing potential instability.
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Which statement correctly defines hyperthermia?
- A. Hyperthermia is a downward shift in the set point.
- B. Hyperthermia is an upward shift in the set point.
- C. Hyperthermia occurs when the body cannot reduce heat production.
- D. Hyperthermia results from a reduction in thermoregulatory mechanisms.
Correct Answer: C
Rationale: Hyperthermia is an uncontrolled rise in body temperature when heat production exceeds dissipation (C), often from external factors or exertion, not set-point shifts. A downward set-point shift (A) isn't hyperthermia. An upward shift (B) defines fever, not hyperthermia. Reduced mechanisms (D) may contribute but isn't the definition. Choice C is correct, distinguishing hyperthermia from fever per nursing pathophysiology, critical for appropriate interventions.
A patient has a head injury and damages the hypothalamus. Which vital sign will the nurse monitor most closely?
- A. Pulse
- B. Temperature
- C. Respirations
- D. Blood pressure
Correct Answer: B
Rationale: The hypothalamus regulates body temperature, so damage from a head injury disrupts thermoregulation, potentially causing hypo- or hyperthermia. Monitoring temperature (B) is critical to detect these shifts, which can indicate injury severity or complications like fever from inflammation. Pulse (A) reflects cardiac response but isn't directly hypothalamic. Respirations (C) may change secondary to brain injury but aren't primarily hypothalamic. Blood pressure (D) can fluctuate with intracranial pressure, yet temperature is the most directly affected vital sign here. Choice B is correct as it aligns with the hypothalamus's role in maintaining thermal homeostasis, a priority in neuro nursing to prevent further brain damage or systemic issues.
A nurse is caring for a group of patients on a medical-surgical unit. Which patient will the nurse assess first?
- A. A 17-year-old male who has just returned from outside 'for a smoke' who needs a temperature taken.
- B. A 20-year-old male postoperative patient whose blood pressure went from 128/70 to 100/60.
- C. A 27-year-old male patient reporting pain whose blood pressure went from 124/70 to 130/74.
- D. An 87-year-old male suspected of hypothermia whose temperature is below normal.
Correct Answer: B
Rationale: A postoperative BP drop from 128/70 to 100/60 (B) indicates potential shock or bleeding, a priority. Smoking (A) or pain with stable BP (C) is less urgent. Hypothermia (D) needs attention but lacks acuity data. Choice B is correct, per triage urgency in surgical care.
The patient's blood pressure is 140/60. Which value will the nurse record for the pulse pressure?
- A. 60
- B. 80
- C. 140
- D. 200
Correct Answer: B
Rationale: Pulse pressure is systolic minus diastolic: 140 - 60 = 80 (B). 60 (A) is diastolic. 140 (C) is systolic. 200 (D) is unrelated. Choice B is correct, reflecting arterial pressure dynamics, a key nursing calculation.
A patient is experiencing pyrexia. Which piece of equipment will the nurse obtain to monitor this condition?
- A. Stethoscope
- B. Thermometer
- C. Blood pressure cuff
- D. Sphygmomanometer
Correct Answer: B
Rationale: Pyrexia (fever) requires temperature monitoring, making a thermometer (B) essential. A stethoscope (A) assesses heart/lung sounds, not temperature. A blood pressure cuff (C) or sphygmomanometer (D) measures pressure, not fever. Choice B is correct as thermometers directly track temperature changes, a fundamental tool in nursing to manage and document febrile states accurately.