Question 1

A student is late for his appointment and has rushed across campus to the health clinic.Before assessing his vital signs,the nurse should:

Accepted Answer

A) allow him time to relax and rest 5 minutes before checking his vital signs. 
B) check the blood pressure in both arms,expecting a difference in the readings because of his recent exercise. 
C) monitor his vital signs immediately on his arrival at the clinic,then 5 minutes later,and note any differences. 
D) check his blood pressure in the supine position because this will give a more accurate reading and allow him to relax at the same time. 
A) allow him time to relax and rest 5 minutes before checking his vital signs. 
B) check the blood pressure in both arms,expecting a difference in the readings because of his recent exercise. 
C) monitor his vital signs immediately on his arrival at the clinic,then 5 minutes later,and note any differences. 
D) check his blood pressure in the supine position because this will give a more accurate reading and allow him to relax at the same time. A

Question 2

When assessing an older adult,the nurse keeps in mind that which vital sign changes occur with aging?

Accepted Answer

A) An increase in pulse rate 
B) A widened pulse pressure 
C) An increase in body temperature 
D) A decrease in diastolic blood pressure 
A) An increase in pulse rate 
B) A widened pulse pressure 
C) An increase in body temperature 
D) A decrease in diastolic blood pressure B

Question 3

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 child's respirations?

Accepted Answer

A) Count the respirations for a full minute,noting rate and rhythm. 
B) Check the child's pulse and respirations simultaneously for 30 seconds. 
C) Check the child's respirations for a minimum of 5 minutes to identify any variations in respiratory pattern. 
D) Count the patient's respirations for 15 seconds and multiply by four to obtain the number of respirations per minute. 
A) Count the respirations for a full minute,noting rate and rhythm. 
B) Check the child's pulse and respirations simultaneously for 30 seconds. 
C) Check the child's respirations for a minimum of 5 minutes to identify any variations in respiratory pattern. 
D) Count the patient's respirations for 15 seconds and multiply by four to obtain the number of respirations per minute. A

Question 4

The nurse is preparing to measure the vital signs of a 6-month-old infant.The nurse will:

Accepted Answer

A) measure respirations and then pulse and temperature. 
B) measure vital signs more frequently than in an adult. 
C) explain procedures and encourage the infant to handle the equipment. 
D) allow the infant to become familiar with the nurse by performing the physical examination first and then measuring the vital signs. 
A) measure respirations and then pulse and temperature. 
B) measure vital signs more frequently than in an adult. 
C) explain procedures and encourage the infant to handle the equipment. 
D) allow the infant to become familiar with the nurse by performing the physical examination first and then measuring the vital signs.

Question 5

When measuring a patient's weight,the examiner keeps in mind which of the following?

Accepted Answer

A) Always weigh the patient with only his or her undergarments on. 
B) It does not matter what type of scale is used,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 this is documented next to the weight. 
D) Attempt to weigh the patient at approximately the same time of day,if a sequence of weights is necessary. 
A) Always weigh the patient with only his or her undergarments on. 
B) It does not matter what type of scale is used,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 this is documented next to the weight. 
D) Attempt to weigh the patient at approximately the same time of day,if a sequence of weights is necessary.

Question 6

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:

Accepted Answer

A) his weight loss is probably from unhealthy eating habits. 
B) chronic diseases such as hypertension cause weight loss. 
C) unexplained weight loss often accompanies short-term illnesses. 
D) his weight loss is probably the result of a mental health dysfunction. 
A) his weight loss is probably from unhealthy eating habits. 
B) chronic diseases such as hypertension cause weight loss. 
C) unexplained weight loss often accompanies short-term illnesses. 
D) his weight loss is probably the result of a mental health dysfunction.

Question 7

When counting an infant's respirations,the nurse will:

Accepted Answer

A) watch the chest rise and fall. 
B) watch the abdomen for movement. 
C) place a hand across the infant's chest. 
D) use a stethoscope to listen to the breath sounds. 
A) watch the chest rise and fall. 
B) watch the abdomen for movement. 
C) place a hand across the infant's chest. 
D) use a stethoscope to listen to the breath sounds.

Question 8

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 9

Which of the following best describes the concept of mean arterial pressure (MAP)?

Accepted Answer

A) MAP is the pressure of the arterial pulse. 
B) MAP reflects the stroke volume of the heart. 
C) It is the pressure forcing blood into the tissues,averaged over the cardiac cycle. 
D) It is an average of the systolic and diastolic blood pressures and reflects tissue perfusion. 
A) MAP is the pressure of the arterial pulse. 
B) MAP reflects the stroke volume of the heart. 
C) It is the pressure forcing blood into the tissues,averaged over the cardiac cycle. 
D) It is an average of the systolic and diastolic blood pressures and reflects tissue perfusion.

Question 10

Which of the following statements is true regarding measurement of blood pressure in children?

Accepted Answer

A) The 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) Use of Doppler device is recommended for accurate blood pressures until adolescence. 
D) The disappearance of phase V Korotkoff can be used for the diastolic reading in children and adults. 
A) The 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) Use of Doppler device is recommended for accurate blood pressures until adolescence. 
D) The disappearance of phase V Korotkoff can be used for the diastolic reading in children and adults.

Question 11

Which of the following factors helps to determine blood pressure?

Accepted Answer

A) Pulse rate 
B) Pulse pressure 
C) Vascular output 
D) Peripheral vascular resistance 
A) Pulse rate 
B) Pulse pressure 
C) Vascular output 
D) Peripheral vascular resistance

Question 12

A 75-year-old man has a history of hypertension and was recently changed to a new antihypertensive drug.He reports feeling dizzy at times.How should the nurse evaluate his blood pressure?

Accepted Answer

A) Assess blood pressure and pulse in the supine,sitting,and standing positions. 
B) Have Mr.Jones walk around the room and assess his blood pressure after activity. 
C) Assess his blood pressure and pulse at the beginning and end of the examination. 
D) Take the blood pressure on the right arm and then 5 minutes later take the blood pressure on the left arm. 
A) Assess blood pressure and pulse in the supine,sitting,and standing positions. 
B) Have Mr.Jones walk around the room and assess his blood pressure after activity. 
C) Assess his blood pressure and pulse at the beginning and end of the examination. 
D) Take the blood pressure on the right arm and then 5 minutes later take the blood pressure on the left arm.

Question 13

When checking for proper blood pressure cuff size,the nurse knows that which of the following is true?

Accepted Answer

A) The standard cuff size is appropriate for all sizes. 
B) The length of the rubber bladder should equal 80% of the person's 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. 
A) The standard cuff size is appropriate for all sizes. 
B) The length of the rubber bladder should equal 80% of the person's 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.

Question 14

When auscultating the blood pressure of a 25-year-old,the nurse 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 patient's blood pressure?

Accepted Answer

A) 200/92 
B) 200/100 
C) 100/200/92 
D) 200/100/92 
A) 200/92 
B) 200/100 
C) 100/200/92 
D) 200/100/92

Question 15

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:

Accepted Answer

A) After menopause,blood pressure in women is usually lower than in men. 
B) A black adult's blood pressure is usually higher than that of whites of the same age. 
C) Blood pressure measurements in overweight people should be the same as those of normal weight. 
D) A teen's blood pressure reading will be lower than that of an adult. 
A) After menopause,blood pressure in women is usually lower than in men. 
B) A black adult's blood pressure is usually higher than that of whites of the same age. 
C) Blood pressure measurements in overweight people should be the same as those of normal weight. 
D) A teen's blood pressure reading will be lower than that of an adult.

Question 16

Cellular metabolism requires a stable core temperature.This requires a balance between heat production and heat loss.Which of the following is a mechanism of heat loss in the body?

Accepted Answer

A) Exercise 
B) Radiation 
C) Metabolism 
D) Food digestion 
A) Exercise 
B) Radiation 
C) Metabolism 
D) Food digestion

Question 17

A 4-month-old child is at the clinic for a well-baby check-up and immunizations.Which of the following actions is most appropriate when the nurse is assessing an infant's vital signs?

Accepted Answer

A) Palpate the infant's radial pulse and note any fluctuations resulting from activity or exercise. 
B) Auscultate an apical rate for 1 minute and assess for any normal irregularities,such as sinus arrhythmia. 
C) Assess the infant's blood pressure by using a stethoscope with a large diaphragm piece to hear the soft muffled Korotkoff sounds. 
D) Watch the infant's chest and count the respiratory rate for 1 minute because the respiratory pattern may vary significantly. 
A) Palpate the infant's radial pulse and note any fluctuations resulting from activity or exercise. 
B) Auscultate an apical rate for 1 minute and assess for any normal irregularities,such as sinus arrhythmia. 
C) Assess the infant's blood pressure by using a stethoscope with a large diaphragm piece to hear the soft muffled Korotkoff sounds. 
D) Watch the infant's chest and count the respiratory rate for 1 minute because the respiratory pattern may vary significantly.

Question 18

The nurse is taking an initial blood pressure on a 72-year-old patient with documented hypertension.How should the nurse proceed?

Accepted Answer

A) Place the cuff on the patient's arm and inflate it 30 mm Hg above the patient's pulse rate. 
B) Inflate the cuff to 200 mm Hg in an attempt to obtain the most accurate systolic reading. 
C) Inflate the blood pressure cuff 30 mm Hg above the point at which the palpated pulse disappears. 
D) Look at the patient's past blood pressure readings and inflate the cuff 30 mm Hg above the highest systolic reading recorded. 
A) Place the cuff on the patient's arm and inflate it 30 mm Hg above the patient's pulse rate. 
B) Inflate the cuff to 200 mm Hg in an attempt to obtain the most accurate systolic reading. 
C) Inflate the blood pressure cuff 30 mm Hg above the point at which the palpated pulse disappears. 
D) Look at the patient's past blood pressure readings and inflate the cuff 30 mm Hg above the highest systolic reading recorded.

Question 19

A patient is being seen in the clinic for complaints of "fainting episodes that started last week." How should the nurse proceed with the examination?

Accepted Answer

A) Take his blood pressure in both arms and thighs. 
B) Assist him to a lying position and begin taking his blood pressure. 
C) Record his blood pressure in the lying,sitting,and standing positions. 
D) Record his blood pressure in the lying and sitting positions and average these numbers to obtain a mean blood pressure. 
A) Take his blood pressure in both arms and thighs. 
B) Assist him to a lying position and begin taking his blood pressure. 
C) Record his blood pressure in the lying,sitting,and standing positions. 
D) Record his blood pressure in the lying and sitting positions and average these numbers to obtain a mean blood pressure.

Question 20

The nurse has collected the following information on a patient: palpated blood pressure-180;auscultated blood pressure-170/100;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

Exam 9: General Survey, measurement, vital Signs

A student is late for his appointment and has rushed across campus to the health clinic.Before assessing his vital signs,the nurse should:

When assessing an older adult,the nurse keeps in mind that which vital sign changes occur with aging?

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 child's respirations?

The nurse is preparing to measure the vital signs of a 6-month-old infant.The nurse will:

When measuring a patient's weight,the examiner keeps in mind which of the following?

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:

When counting an infant's respirations,the nurse will:

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

Which of the following best describes the concept of mean arterial pressure (MAP)?

Which of the following statements is true regarding measurement of blood pressure in children?

Which of the following factors helps to determine blood pressure?

A 75-year-old man has a history of hypertension and was recently changed to a new antihypertensive drug.He reports feeling dizzy at times.How should the nurse evaluate his blood pressure?

When checking for proper blood pressure cuff size,the nurse knows that which of the following is true?

When auscultating the blood pressure of a 25-year-old,the nurse 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 patient's blood pressure?

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:

Cellular metabolism requires a stable core temperature.This requires a balance between heat production and heat loss.Which of the following is a mechanism of heat loss in the body?

A 4-month-old child is at the clinic for a well-baby check-up and immunizations.Which of the following actions is most appropriate when the nurse is assessing an infant's vital signs?

The nurse is taking an initial blood pressure on a 72-year-old patient with documented hypertension.How should the nurse proceed?

A patient is being seen in the clinic for complaints of "fainting episodes that started last week." How should the nurse proceed with the examination?

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

Critical Thinking in Health Assessment

Developmental Tasks and Health Promotion Across the Life Cycle

Cultural Competence: Cultural Care

The Interview

The Complete Health History

Mental Status 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

Reassessment of the Hospitalized Adult

The Pregnant Female

Functional Assessment of the Older Adult

Filters