1. The nurse is performing a general survey. Which action is a component of the general survey? Show Observing the patients body stature and nutritional status b. Interpreting the subjective information the patient has reported c. Measuring the patients temperature, pulse, respirations, and blood pressure d. Observing specific body systems while performing the physical assessment Observing
the patients body stature and nutritional status 3. A patients weekly blood pressure readings for 2 months have ranged between 124/84 mm Hg and 136/88 mm Hg, with an average reading of 126/86 mm Hg. The nurse knows that this blood pressure falls within which blood pressure category? The patient is always weighed wearing only his or her undergarments. b. The type of scale does not matter, as long as the weights are similar from day to day. c. The patient may leave on his or her jacket and shoes as long as these are documented next to the weight. d. Attempts should be made to weigh the patient at approximately the same time of day, if a sequence of weights is necessary. Prehypertension- prehypertension blood pressure readings are systolic readings of 120 to 139 mm Hg or diastolic readings of 50 to 89 mm Hg. 4. During an examination of a child, the nurse considers that physical growth is the best index of a childs: a. General health. b. Genetic makeup. c. Nutritional status. d. Activity and exercise patterns. general health 5. A 1-month-old infant has a head measurement of 34 cm and has a chest circumference of 32 cm. Based on the interpretation of these findings, the nurse would: Refer the infant to a physician for further evaluation. b. Consider these findings normal for a 1-month-old infant. c. Expect the chest circumference to be greater than the head circumference. d. Ask the parent to return in 2 weeks to re-evaluate the head and chest circumferences. normal- 6. The nurse is assessing an 80-year-old male patient. Which assessment findings would be considered
normal? Increase in body weight from his younger years b. Additional deposits of fat on the thighs and lower legs c. Presence of kyphosis and flexion in the knees and hips d. Change in overall body proportion, including a longer trunk and shorter extremities Presence of kyphosis (hunch back) and flexion in the knees and hips 7. The nurse should measure rectal
temperatures in which of these patients? School-age child b. Older adult c. Comatose adult d. Patient receiving oxygen by nasal cannula comatose adult 8. The nurse is preparing to measure the length, weight, chest, and head circumference of a 6-month-old infant. Which measurement technique is correct? Measuring the infants length by using a tape measure b. Weighing the infant by placing him or her on an electronic standing scale c. Measuring the chest circumference at the nipple line with a tape measure d. Measuring the head circumference by wrapping the tape measure over the nose and cheekbones To measure the chest circumference, the tape is encircled around the chest at the nipple line. The length should be measured on a horizontal measuring board. Weight should be measured on a platform-type balance scale. Head circumference is measured with the tape around the head, aligned at the eyebrows, and at the prominent frontal and occipital bonesthe widest span is correct. 9. The nurse knows that one advantage of the tympanic membrane thermometer (TMT) is that: Rapid measurement is useful for uncooperative younger children. b. Using the TMT is the most accurate method for measuring body temperature in newborn infants. c. Measuring temperature using the TMT is inexpensive. d. Studies strongly support the use of the TMT in children under the age 6 years. rapid measurement is useful in uncooperative younger children 10. When assessing an older adult, which vital sign changes occur with aging? Increase in pulse rate b. Widened pulse pressure c. Increase in body temperature d. Decrease in diastolic blood pressure widened pulse pressure 11. The nurse is examining a patient who is complaining of feeling cold. Which is a mechanism of heat loss in the body? a. Exercise b. Radiation c. Metabolism d. Food digestion radiation 12. When measuring a patients body temperature, the nurse keeps in mind that body temperature is influenced by: Constipation. b. Patients emotional state. c. Diurnal cycle. d. Nocturnal cycle. diurnal cycle 13. When evaluating the temperature of older adults, the nurse should remember which aspect about an older adults body temperature? The body temperature of the older adult is lower than that of a younger adult. b. An older adults body temperature is approximately the same as that of a young child. c. Body temperature depends on the type of thermometer used. d. In the older adult, the body temperature varies widely because of less effective heat control mechanisms. The body temperature of the older adult is lower than that of a younger adult. 14. A 60-year-old male patient has been treated for pneumonia for the past 6 weeks. He is seen today in the clinic for an unexplained weight loss of 10 pounds over the last 6 weeks. The nurse
knows that: Weight loss is probably the result of unhealthy eating habits. b. Chronic diseases such as hypertension cause weight loss. c. Unexplained weight loss often accompanies short-term illnesses. d. Weight loss is probably the result of a mental health dysfunction. Unexplained weight loss often accompanies short-term illnesses. 15. When assessing a
75-year-old patient who has asthma, the nurse notes that he assumes a tripod position, leaning forward with arms braced on the chair. On the basis of this observation, the nurse should: Assume that the patient is eager and interested in participating in the interview. b. Evaluate the patient for abdominal pain, which may be exacerbated in the sitting position. c. Assume that the patient is having difficulty breathing and assist him to a supine position. d. Recognize that a tripod position is often used when a patient is having respiratory difficulties. Recognize that a tripod position is often used when a patient is having respiratory difficulties. 16. Which of these actions illustrates the correct technique the nurse should use when assessing oral temperature with a mercury thermometer? Wait 30 minutes if the patient has ingested hot or iced liquids. b. Leave the thermometer in place 3 to 4 minutes if the patient is afebrile. c. Place the thermometer in front of the tongue, and ask the patient to close his or her lips. d. Shake the mercury-in-glass thermometer down to below 36.6 C before taking the temperature. Leave the thermometer in place 3 to 4 minutes if the patient is afebrile. 17. The nurse is taking
temperatures in a clinic with a TMT. Which statement is true regarding use of the TMT? A tympanic temperature is more time consuming than a rectal temperature. b. The tympanic method is more invasive and uncomfortable than the oral method. c. The risk of cross-contamination is reduced, compared with the rectal route. d. The tympanic membrane most accurately reflects the temperature in the ophthalmic artery. The risk of cross-contamination is reduced, compared with the rectal route. 18. To assess a rectal temperature accurately in an adult, the nurse would: Use a lubricated blunt tip thermometer. b. Insert the thermometer 2 to 3 inches into the rectum. c. Leave the thermometer in place up to 8 minutes if the patient is febrile. d. Wait 2 to 3 minutes if the patient has recently smoked a cigarette. Use a lubricated blunt tip thermometer. 19. Which technique is correct when the nurse is assessing the radial pulse of a patient? The pulse is counted for: 30-second interval multiplied by 2 is the most accurate and efficient technique when heart rates are normal or rapid and when rhythms are regular. If the rhythm is irregular, then the pulse is counted for 1 full minute. 20. When assessing a patients pulse, the nurse should also notice which of these characteristics? a. Force b. Pallor c. Capillary refill time d. Timing in the cardiac cycle The pulse is assessed for rate, rhythm, and force. 21. When assessing the pulse of a 6-year-old boy, the nurse notices that his heart
rate varies with his respiratory cycle, speeding up at the peak of inspiration and slowing to normal with expiration. The nurses next action would be to: Immediately notify the physician. b. Consider this finding normal in children and young adults. c. Check the childs blood pressure, and note any variation with respiration. d. Document that this child has bradycardia, and continue with the assessment. Normal-sinus arrhythmia is commonly found in children and young adults. During the respiratory cycle, the heart rate varies, speeding up at the peak of inspiration and slowing to normal with expiration. 22. When assessing the force, or strength, of a pulse, the nurse recalls that the pulse: a. Is usually recorded on a 0- to 2-point scale. b. Demonstrates elasticity of the vessel wall. c. Is a reflection of the hearts stroke volume. d. Reflects the blood volume in the arteries during diastole. Is a reflection of the hearts stroke volume. 23. The nurse is assessing the vital signs of a 20-year-old male marathon runner and documents the following vital signs: temperature36 C; pulse48 beats per minute; respirations14 breaths per minute; blood pressure104/68 mm Hg. Which statement is true concerning these results? normal 24. The nurse is assessing the vital signs of a 3-year-old patient who appears to have an irregular respiratory pattern. How should the nurse assess this childs respirations? Respirations should be counted for 1 full minute, noticing rate and rhythm. 25. A patients blood pressure is 118/82 mm Hg. He asks the nurse, What do the numbers mean? The nurses best reply is: a. The numbers are within the normal range and are nothing to worry about. b. The bottom number is the diastolic pressure and reflects the stroke volume of the heart. c. The top number is the systolic blood pressure and reflects the pressure of the blood against the arteries when the heart contracts. d. The concept of blood pressure is difficult to understand. The primary thing to be concerned about is the top number, or the systolic blood pressure. The top number is the systolic blood pressure and reflects the pressure of the blood against the arteries when the heart contracts 26. While measuring a patients blood pressure, the nurse recalls that certain factors, such as __________, help determine blood pressure. a. Pulse rate b. Pulse pressure c. Vascular output d. Peripheral vascular resistance Peripheral vascular resistance 27. A nurse is helping at a health fair at a local mall. When taking blood pressures on a variety of people, the nurse keeps in mind that: After menopause, blood pressure readings in women are usually lower than those taken in men. b. The blood pressure of a Black adult is usually higher than that of a White adult of the same age. c. Blood pressure measurements in people who are overweight should be the same as those of people who are at a normal weight. d. A teenagers blood pressure reading will be lower than that of an adult. The blood pressure of a Black adult is usually higher than that of a White adult of the same age. 30. The nurse will perform a palpated pressure before auscultating blood pressure. The reason for this is to: More clearly hear the Korotkoff sounds. b. Detect the presence of an auscultatory gap. c. Avoid missing a falsely elevated blood pressure. d. More readily identify phase IV of the Korotkoff sounds. Detect the presence of an auscultatory gap 31.
The nurse is taking an initial blood pressure reading on a 72-year-old patient with documented hypertension. How should the nurse proceed? Cuff should be placed on the patients arm and inflated 30 mm Hg above the patients pulse rate. b. Cuff should be inflated to 200 mm Hg in an attempt to obtain the most accurate systolic reading. c. Cuff should be inflated 30 mm Hg above the point at which the palpated pulse disappears. d. After confirming the patients previous blood pressure readings, the cuff should be inflated 30 mm Hg above the highest systolic reading recorded. Cuff should be inflated 30 mm Hg above the point at which the palpated pulse disappears. 32. The nurse has collected the following information on a patient: palpated blood pressure180 mm Hg; auscultated blood pressure170/100 mm Hg; apical pulse60 beats per minute; radial pulse70 beats per minute. What is the patients pulse pressure? a. 10 b. 70 c. 80 d. 100 pulse pressure 33. When auscultating the blood pressure of a 25-year-old patient, the nurse notices the phase I Korotkoff sounds begin at 200 mm Hg. At 100 mm Hg, the Korotkoff sounds muffle. At 92 mm Hg, the Korotkoff sounds disappear. How should the nurse record this patients blood pressure? 200/92 34. A patient is seen in the clinic for complaints of fainting episodes that started last week. How should the nurse proceed with the examination? b.The patient is assisted to a lying position, and his blood pressure is taken. c.His blood pressure is recorded in the lying, sitting, and standing positions. d.His blood pressure is recorded in the lying and sitting positions; these numbers are then averaged to obtain a mean blood pressure. His blood pressure is recorded in the lying, sitting, and standing positions. 35. A 70-year-old man has a blood pressure of 150/90 mm Hg in a lying position, 130/80 mm Hg in a sitting position, and 100/60 mm Hg in a standing position. How should the nurse evaluate these findings? Orthostatic hypotension 36. The nurse is helping another nurse to take a blood pressure reading on a patients thigh. Which action is correct regarding thigh pressure? a.Either the popliteal or femoral vessels should be auscultated to obtain a thigh pressure. b.The best position to measure thigh pressure is the supine position with the knee slightly bent. c.If the blood pressure in the arm is high in an adolescent, then it should be compared with the thigh pressure. d.The thigh pressure is lower than the pressure in the arm, which is attributable to the distance away from the heart and the size of the popliteal vessels. If the blood pressure in the arm is high in an
adolescent, then it should be compared with the thigh pressure. 37. The nurse is preparing to measure the vital signs of a 6-month-old infant. Which action by the nurse is correct? a. Respirations are measured; then pulse and temperature. b. Vital signs should be measured more frequently than in an adult. c. Procedures are explained to the parent, and the infant is encouraged to handle the equipment. d. The nurse should first perform the physical examination to allow the infant to become more familiar with her and then measure the infants vital signs. Respirations are measured; then pulse and temperature. 38. A 4-month-old child is at the clinic for a well-baby check-up and immunizations. Which of these actions is most appropriate when the nurse is assessing an infants vital signs? a. The infants radial pulse should be palpated, and the nurse should notice any fluctuations resulting from activity or exercise. b. The nurse should auscultate an apical rate for 1 minute and then assess for any normal irregularities, such as sinus arrhythmia. c. The infants blood pressure should be assessed by using a stethoscope with a large diaphragm piece to hear the soft muffled Korotkoff sounds. d. The infants chest should be observed and the respiratory rate counted for 1 minute; the respiratory pattern may vary significantly. The nurse should auscultate an apical rate for 1 minute and then assess for any normal irregularities, such as sinus arrhythmia 39. The nurse is conducting a health fair for older adults. Which statement is true regarding vital sign measurements in aging adults? a. The pulse is more difficult to palpate because of the stiffness of the blood vessels. b. An increased respiratory rate and a shallower inspiratory phase are expected findings. c. A decreased pulse pressure occurs from changes in the systolic and diastolic blood pressures. d. Changes in the bodys temperature regulatory mechanism leave the older person more likely to develop a fever. An increased respiratory rate and a shallower inspiratory phase are expected findings. 40. In a patient with acromegaly, the nurse will expect to discover which assessment findings? Overgrowth of bone in the face, head, hands, and feet 41. The nurse is performing a general survey of a patient. Which finding is considered normal? a. When standing, the patients base is narrow. b. The patient appears older than his stated age. c. Arm span (fingertip to fingertip) is greater than the height. d. Arm span (fingertip to fingertip) equals the patients height. Arm span (fingertip to fingertip) equals the patients height. 42. The nurse is assessing children in a pediatric clinic. Which statement is true regarding the measurement of blood pressure in children? a. Blood pressure guidelines for children are based on age. b. Phase II Korotkoff sounds are the best indicator of systolic blood pressure in children. c. Using a Doppler device is recommended for accurate blood pressure measurements until adolescence. d. The disappearance of phase V Korotkoff sounds can be used for the diastolic reading in children. The disappearance of phase V Korotkoff sounds can be used for the diastolic reading in children. (as well as adults) 43. What type of blood pressure measurement error is most likely to occur if the nurse does not check for the presence of an auscultatory gap? Systolic blood pressure may be falsely low. 44. When considering the concepts related to blood pressure, the nurse knows that the concept of mean arterial pressure (MAP) is best described by which statement? b.MAP reflects the stroke volume of the heart. c.MAP is the pressure forcing blood into the tissues, averaged over the cardiac cycle. d.MAP is an average of the systolic and diastolic blood pressures and reflects tissue perfusion. MAP is the pressure forcing blood into the tissues, averaged over the cardiac cycle. 45. A 75-year-old man with a history of hypertension was recently changed to a new antihypertensive drug. He reports feeling dizzy at times. How should the nurse evaluate his blood pressure? a.Blood pressure and pulse should be recorded in the supine, sitting, and standing positions. b.The patient should be directed to walk around the room and his blood pressure assessed after this activity. c.Blood pressure and pulse are assessed at the beginning and at the end of the examination. d.Blood pressure is taken on the right arm and then 5 minutes later on the left arm. Blood pressure and pulse should be recorded in the supine, sitting, and standing
positions. 46. Which of these specific measurements is the best index of a childs general health? height and weight 47. The nurse is assessing an 8-year-old child whose growth rate measures below the third percentile for a child his age. He appears significantly younger than his stated age and is chubby with infantile facial features. Which condition does this child have? Hypopituitary dwarfism is caused by a deficiency in growth hormone in childhood and results in a retardation of growth below the third percentile, delayed puberty, and other problems. 48. The nurse is counting an infants respirations. Which technique is correct? b.Watching the abdomen for movement c.Placing a hand across the infants chest d.Using a stethoscope to listen to the breath sounds Watching the abdomen for movement is the correct technique because the infants respirations are normally more diaphragmatic than thoracic. 49. When checking for proper blood pressure cuff size, which guideline is correct? b.The length of the rubber bladder should equal 80% of the arm circumference. c.The width of the rubber bladder should equal 80% of the arm circumference. d.the width of the rubber bladder should equal 40% of the arm circumference. The width of the rubber bladder should equal 40% of the circumference of the persons arm. The length of the bladder should equal 80% of this circumference. 50. During an examination, the nurse notices that a female patient has a round moon face, central trunk obesity, and a cervical hump. Her skin is fragile with bruises. The nurse determines that the patient has which condition? Cushing syndrome 1. While measuring a patients blood pressure, the nurse uses the proper technique to obtain an accurate reading. Which of these situations will result in a falsely high blood pressure reading? Select all that apply: The person supports his or her own arm during the blood pressure reading The blood pressure cuff is too narrow for the extremity. The arm is held above level of the heart. The cuff is loosely wrapped around the arm. The person is sitting with his or her legs crossed. The nurse does not inflate the cuff high enough. A, B, D,E 1. What is the pulse pressure for a patient whose blood pressure is 158/96 mm Hg and whose pulse rate is 72 beats per minute? 62 BMI calculation?? weight/height(in) squared multiplied by703 with every heart beat, the heart pumps an amount of blood into the aorta: stroke volume -70 mL for adults The force of blood flares arterial walls and generates a pressure wave which is known as a: pulse heart rate varies w/ the respiratory cycle. Speeding up at the peak of inspiration and slowing to normal during expiration: sinus arrythmia Force of pulse @ 3+ full, bounding Force of pulse @ 2+ Normal Force of pulse @ 1+ weak, thready
max pressure felt on the artery during left ventricular contraction systolic pressure elastic, recoil resisting pressure the blood exerts constantly b/t each contraction: diastolic pressure the pulse pressure is the: difference between systole and diastole congenital form of aorta narrowing: coarctation The general survey consists of four distinct areas. These areas include: A) mental status, speech, behavior, and mood and affect. c An 18-month-old child is brought into the clinic for a health screening visit. To assess the height of the child: A) Use a tape measure. B Which changes regarding height and weight occur during the 80s and 90s? A) Both increase. c During an initial home visit, the patient's temperature is noted to be 97.4F. How would you interpret this? A) It cannot be evaluated without knowledge of the person's age. a After assessing the patient's pulse, the practitioner determines it to be "normal." This would be recorded as: A) 3+ b Pulse pressure is described as: A) The difference between the systolic and diastolic pressure. a MAP is? diastolic pressure plus 1/3 of the pulse pressure the nurse is conducting a health fair for older adults, which statement is true regarding vital sign measurements in aging adults? an increased respiratory rate and a shallower inspiratory phase are possible findings Which action is a component of the general survey quizlet?Which action is a component of the general survey? (The general survey is a study of the whole person that includes observing the patient's physical appearance, body structure, mobility, and behavior.
Which of the following is part of the general survey?The general survey consists of a patient's age, weight, height, build, posture, gait and hygiene. Nurses use health assessments to obtain baseline data about patients and to build a rapport with them that can ease anxiety and lead to a trusting relationship.
When performing a general survey the examiner is?1. When performing a general survey, the examiner is: 1. observing the patient's body stature and nutritional status.
When performing an examination the nurse should consider a child's physical growth to be the best indicator of which aspect of health?Physical growth is the best index of a child's general health; recording the child's height and weight helps determine normal growth patterns. A child's physical growth is not the best indicator of genetic makeup, nutritional status, or activity and exercise patterns. 4.
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The nurse is performing a general survey of a patient. which finding is considered normal? quizlet
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