Question 1

The nurse is performing a general survey.Which finding is considered normal?

Accepted Answer

A)  When standing, the patient's 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 height. 
A)  When standing, the patient's 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 height.

Question 2

The nurse is assessing the vital signs of a 20-year-old male marathon runner and documents the following vital signs: temperature-97° F;pulse-48 beats per minute;respirations-14 per minute;blood pressure-104/68 mm Hg.Which statement is true about these results?

Accepted Answer

A)  The patient is experiencing tachycardia. 
B)  These are normal vital signs for a healthy, athletic adult. 
C)  The patient's pulse rate is not normal-his physician should be notified. 
D)  On the basis of today's readings, the patient should return to the clinic in 1 week. 
A)  The patient is experiencing tachycardia. 
B)  These are normal vital signs for a healthy, athletic adult. 
C)  The patient's pulse rate is not normal-his physician should be notified. 
D)  On the basis of today's readings, the patient should return to the clinic in 1 week.

Question 3

The nurse is assessing an 8-year-old child whose growth rate measures below the third percentile for a child his age.He appears much younger than his stated age,and he is chubby with infantile facial features.Which condition does this child have?

Accepted Answer

A)  Hypopituitary dwarfism 
B)  Achondroplastic dwarfism 
C)  Marfan syndrome 
D)  Acromegaly 
A)  Hypopituitary dwarfism 
B)  Achondroplastic dwarfism 
C)  Marfan syndrome 
D)  Acromegaly

Question 4

Which technique is correct when the nurse is assessing the radial pulse of a patient? Count the:

Accepted Answer

A)  pulse for 1 minute if the rhythm is irregular. 
B)  pulse for 15 seconds and multiply by four, if the rhythm is regular. 
C)  initial pulse for a full 2 minutes to detect any variation in amplitude. 
D)  pulse for 10 seconds and multiply by six, if the patient has no history of cardiac abnormalities. 
A)  pulse for 1 minute if the rhythm is irregular. 
B)  pulse for 15 seconds and multiply by four, if the rhythm is regular. 
C)  initial pulse for a full 2 minutes to detect any variation in amplitude. 
D)  pulse for 10 seconds and multiply by six, if the patient has no history of cardiac abnormalities.

Question 5

In a patient with acromegaly,the nurse will expect to discover which assessment findings?

Accepted Answer

A)  Heavy, flattened facial features 
B)  Growth retardation and a delayed onset of puberty 
C)  Overgrowth of bone in the face, head, hands, and feet 
D)  Increased height and weight and delayed sexual development 
A)  Heavy, flattened facial features 
B)  Growth retardation and a delayed onset of puberty 
C)  Overgrowth of bone in the face, head, hands, and feet 
D)  Increased height and weight and delayed sexual development

Question 6

The nurse has collected the following information on a patient: palpated blood pressure-180;auscultated blood pressure-170/100 mm Hg;apical pulse-60;radial pulse-70.What is the patient's pulse pressure?

Accepted Answer

A)  10 
B)  70 
C)  80 
D)  100 
A)  10 
B)  70 
C)  80 
D)  100

Question 7

Which of these actions illustrates the correct technique the nurse should use when assessing oral temperature with a mercury thermometer?

Accepted Answer

A)  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 have the patient close his or her lips. 
D)  Shake the mercury-in-glass thermometer down to 98° F before taking the temperature. 
A)  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 have the patient close his or her lips. 
D)  Shake the mercury-in-glass thermometer down to 98° F before taking the temperature.

Question 8

The nurse is performing a general survey.Which action is a component of the general survey?

Accepted Answer

A)  Observing the patient's body stature and nutritional status 
B)  Interpreting the subjective information the patient has reported 
C)  Measuring the patient's temperature, pulse, respirations, and blood pressure 
D)  Observing specific body systems while performing the physical assessment 
A)  Observing the patient's body stature and nutritional status 
B)  Interpreting the subjective information the patient has reported 
C)  Measuring the patient's temperature, pulse, respirations, and blood pressure 
D)  Observing specific body systems while performing the physical assessment

Question 9

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?

Accepted Answer

62
The pulse pressure is the d

Question 10

The nurse is taking temperatures in a clinic with a tympanic thermometer.Which statement is true regarding use of the tympanic thermometer?

Accepted Answer

A)  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)  There is a reduced risk of cross-contamination compared with the rectal route. 
D)  The tympanic membrane most accurately reflects the temperature in the ophthalmic artery. 
A)  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)  There is a reduced risk of cross-contamination compared with the rectal route. 
D)  The tympanic membrane most accurately reflects the temperature in the ophthalmic artery.

Question 11

To accurately assess a rectal temperature on an adult,the nurse would:

Accepted Answer

A)  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. 
A)  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.

Question 12

The nurse should measure rectal temperatures in which of these patients?

Accepted Answer

A)  School-age child 
B)  Elderly adult 
C)  Comatose adult 
D)  Patient receiving oxygen by nasal cannula 
A)  School-age child 
B)  Elderly adult 
C)  Comatose adult 
D)  Patient receiving oxygen by nasal cannula

Exam 9: General Survey, Measurement, Vital Signs

The nurse is performing a general survey.Which finding is considered normal?

The nurse is assessing the vital signs of a 20-year-old male marathon runner and documents the following vital signs: temperature-97° F;pulse-48 beats per minute;respirations-14 per minute;blood pressure-104/68 mm Hg.Which statement is true about these results?

The nurse is assessing an 8-year-old child whose growth rate measures below the third percentile for a child his age.He appears much younger than his stated age,and he is chubby with infantile facial features.Which condition does this child have?

Which technique is correct when the nurse is assessing the radial pulse of a patient? Count the:

In a patient with acromegaly,the nurse will expect to discover which assessment findings?

The nurse has collected the following information on a patient: palpated blood pressure-180;auscultated blood pressure-170/100 mm Hg;apical pulse-60;radial pulse-70.What is the patient's pulse pressure?

Which of these actions illustrates the correct technique the nurse should use when assessing oral temperature with a mercury thermometer?

The nurse is performing a general survey.Which action is a component of the general survey?

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?

The nurse is taking temperatures in a clinic with a tympanic thermometer.Which statement is true regarding use of the tympanic thermometer?

To accurately assess a rectal temperature on an adult,the nurse would:

The nurse should measure rectal temperatures in which of these patients?

Evidence Based Assessment

Cultural Competence: Cultural Care

The Interview

The Complete Health History

Mental Status Assessment

Substance Use Assessment

Domestic Violence Assessment

Assessment Techniques and the Clinical Setting

Pain Assessment: The Fifth Vital Sign

Nutritional Assessment

Skin, Hair, and Nails

Head, Face, and Neck, Including Regional Lymphatics

Eyes

Ears

Nose, Mouth, and Throat

Breasts and Regional Lymphatics

Thorax and Lungs

Heart and Neck Vessels

Peripheral Vascular System and Lymphatic System

Abdomen

Musculoskeletal System

Neurologic System

Male Genitourinary System

Anus, Rectum, and Prostate

Female Genitourinary System

The Complete Health Assessment: Putting It All Together

Bedside Assessment of the Hospitalized Adult

The Pregnant Woman

Functional Assessment of the Older Adult

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