Question 1

When assessing the radial pulse of a patient,the nurse should 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 2

Physical growth is the best index of a child's:

Accepted Answer

A) general health. 
B) genetic makeup. 
C) nutritional status. 
D) activity and exercise patterns. 
A) general health. 
B) genetic makeup. 
C) nutritional status. 
D) activity and exercise patterns.

Question 3

When measuring a patient's body temperature,the nurse keeps in mind that body temperature is influenced by:

Accepted Answer

A) constipation. 
B) patient's emotional state. 
C) the diurnal cycle. 
D) the nocturnal cycle. 
A) constipation. 
B) patient's emotional state. 
C) the diurnal cycle. 
D) the nocturnal cycle.

Question 4

A 1-month-old infant has a head measurement of 34 cm and has a chest circumference of 32 cm.The nurse would:

Accepted Answer

A) refer the infant to a physician for further evaluation. 
B) consider this a normal finding 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. 
A) refer the infant to a physician for further evaluation. 
B) consider this a normal finding 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.

Question 5

When assessing an 80-year-old male patient,which of the following findings would be considered normal?

Accepted Answer

A) An increase in body weight from younger years 
B) Additional deposits of fat on the thighs and lower legs 
C) The presence of kyphosis and flexion in the knees and hips 
D) A change in overall body proportion,a longer trunk,and shorter extremities 
A) An increase in body weight from younger years 
B) Additional deposits of fat on the thighs and lower legs 
C) The presence of kyphosis and flexion in the knees and hips 
D) A change in overall body proportion,a longer trunk,and shorter extremities

Question 6

A patient's weekly blood pressure readings for 2 months have ranged between 124/84 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?

Accepted Answer

A) Normal blood pressure 
B) Prehypertension 
C) Stage I hypertension 
D) Stage 2 hypertension 
A) Normal blood pressure 
B) Prehypertension 
C) Stage I hypertension 
D) Stage 2 hypertension

Question 7

The nurse should measure rectal temperatures in which of the following patients?

Accepted Answer

A) A school-age child 
B) An elderly adult 
C) A comatose adult 
D) A patient who is receiving oxygen by nasal cannula 
A) A school-age child 
B) An elderly adult 
C) A comatose adult 
D) A patient who is receiving oxygen by nasal cannula

Question 8

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 9

When assessing the pulse of a 6-year-old boy,the nurse notes that his heart rate varies with his respiratory cycle,speeding up at the peak of inspiration and slowing to normal with expiration.The nurse would:

Accepted Answer

A) notify the physician immediately. 
B) consider this a normal finding in children and young adults. 
C) check the child's blood pressure and note any variation with respiration. 
D) document that this child has bradycardia and continue with the assessment. 
A) notify the physician immediately. 
B) consider this a normal finding in children and young adults. 
C) check the child's blood pressure and note any variation with respiration. 
D) document that this child has bradycardia and continue with the assessment.

Question 10

Which is true regarding the force,or strength,of the pulse? It:

Accepted Answer

A) is usually recorded on a 0- to 2-point scale. 
B) demonstrates elasticity of the vessel wall. 
C) is a reflection of the heart's stroke volume. 
D) reflects the blood volume in the arteries during diastole. 
A) is usually recorded on a 0- to 2-point scale. 
B) demonstrates elasticity of the vessel wall. 
C) is a reflection of the heart's stroke volume. 
D) reflects the blood volume in the arteries during diastole.

Question 11

During an examination,the nurse notes that a female patient has a round "moon" face,central trunk obesity,and a cervical hump.Her skin is fragile with bruises.The nurse notes that the patient has which condition?

Accepted Answer

A) Marfan's syndrome 
B) Gigantism 
C) Cushing's syndrome 
D) Acromegaly 
A) Marfan's syndrome 
B) Gigantism 
C) Cushing's syndrome 
D) Acromegaly

Question 12

In a patient with acromegaly,the nurse will expect to observe:

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 13

Which of the following statements is true regarding thigh pressure?

Accepted Answer

A) Auscultate either the popliteal or femoral vessels 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,compare it with the thigh pressure. 
D) The thigh pressure is lower than that in the arm due to distance away from the heart and the size of the popliteal vessels. 
A) Auscultate either the popliteal or femoral vessels 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,compare it with the thigh pressure. 
D) The thigh pressure is lower than that in the arm due to distance away from the heart and the size of the popliteal vessels.

Question 14

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 would:

Accepted Answer

A) 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. 
A) 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.

Question 15

Which of the following describes 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 16

A 70-year-old man has a blood pressure of 150/90 in a lying position,130/80 in a sitting position,and 100/60 in a standing position.How should the nurse evaluate these findings?

Accepted Answer

A) This is a normal response due to changes in the patient's position. 
B) The change in blood pressure readings is called orthostatic hypotension. 
C) The blood pressure reading in the lying position is within normal limits. 
D) The change in blood pressure reading is considered within normal limits for the patient's age. 
A) This is a normal response due to changes in the patient's position. 
B) The change in blood pressure readings is called orthostatic hypotension. 
C) The blood pressure reading in the lying position is within normal limits. 
D) The change in blood pressure reading is considered within normal limits for the patient's age.

Question 17

Which of the following statements is true regarding vital sign measurements in aging adults?

Accepted Answer

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 systolic and diastolic blood pressures. 
D) Changes in the body's temperature regulatory mechanism leave the aging person more likely to develop a fever. 
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 systolic and diastolic blood pressures. 
D) Changes in the body's temperature regulatory mechanism leave the aging person more likely to develop a fever.

Question 18

The nurse is preparing to measure the length,weight,chest,and head circumference of a 6-month-old infant.The nurse would measure the infant's:

Accepted Answer

A) length by using a tape measure. 
B) weight by placing him on an electronic standing scale. 
C) chest circumference at the nipple line with a tape measure. 
D) head circumference by wrapping the tape measure over the nose and cheekbones. 
A) length by using a tape measure. 
B) weight by placing him on an electronic standing scale. 
C) chest circumference at the nipple line with a tape measure. 
D) head circumference by wrapping the tape measure over the nose and cheekbones.

Question 19

The nurse will perform a palpated pressure before auscultating blood pressure.The reason for this is to:

Accepted Answer

A) hear the Korotkoff sounds more clearly. 
B) detect the presence of an auscultatory gap. 
C) avoid missing a falsely elevated blood pressure. 
D) identify phase IV of the Korotkoff sounds more readily. 
A) hear the Korotkoff sounds more clearly. 
B) detect the presence of an auscultatory gap. 
C) avoid missing a falsely elevated blood pressure. 
D) identify phase IV of the Korotkoff sounds more readily.

Question 20

Which of the following specific measurements is the best index of a child's general health?

Accepted Answer

A) Vital signs 
B) Height and weight 
C) Head circumference 
D) Chest circumference 
A) Vital signs 
B) Height and weight 
C) Head circumference 
D) Chest circumference

Exam 9: General Survey, measurement, vital Signs

When assessing the radial pulse of a patient,the nurse should count the:

Physical growth is the best index of a child's:

When measuring a patient's body temperature,the nurse keeps in mind that body temperature is influenced by:

A 1-month-old infant has a head measurement of 34 cm and has a chest circumference of 32 cm.The nurse would:

When assessing an 80-year-old male patient,which of the following findings would be considered normal?

A patient's weekly blood pressure readings for 2 months have ranged between 124/84 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 nurse should measure rectal temperatures in which of the following patients?

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

When assessing the pulse of a 6-year-old boy,the nurse notes that his heart rate varies with his respiratory cycle,speeding up at the peak of inspiration and slowing to normal with expiration.The nurse would:

Which is true regarding the force,or strength,of the pulse? It:

During an examination,the nurse notes that a female patient has a round "moon" face,central trunk obesity,and a cervical hump.Her skin is fragile with bruises.The nurse notes that the patient has which condition?

In a patient with acromegaly,the nurse will expect to observe:

Which of the following statements is true regarding thigh pressure?

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 would:

Which of the following describes the correct technique the nurse should use when assessing oral temperature with a mercury thermometer?

A 70-year-old man has a blood pressure of 150/90 in a lying position,130/80 in a sitting position,and 100/60 in a standing position.How should the nurse evaluate these findings?

Which of the following statements is true regarding vital sign measurements in aging adults?

The nurse is preparing to measure the length,weight,chest,and head circumference of a 6-month-old infant.The nurse would measure the infant's:

The nurse will perform a palpated pressure before auscultating blood pressure.The reason for this is to:

Which of the following specific measurements is the best index of a child's general health?

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

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