Question 1

A patient's BP is 118/82 mm Hg.He asks the nurse to explain "what the numbers mean." The nurse's best reply would be:

Accepted Answer

A) "The numbers are within normal range and 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 BP and reflects the pressure on the arteries when the heart contracts." 
D) "The concept of BP is difficult to understand.The main thing to be concerned about is the top number,or systolic blood pressure." 
A) "The numbers are within normal range and 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 BP and reflects the pressure on the arteries when the heart contracts." 
D) "The concept of BP is difficult to understand.The main thing to be concerned about is the top number,or systolic blood pressure."

Question 2

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 3

What type of BP measurement error is most likely to occur if the examiner does not check for the presence of an auscultatory gap?

Accepted Answer

A) The diastolic BP may not be heard. 
B) The diastolic BP may be falsely low. 
C) The systolic BP may be falsely low. 
D) The systolic BP may be falsely high. 
A) The diastolic BP may not be heard. 
B) The diastolic BP may be falsely low. 
C) The systolic BP may be falsely low. 
D) The systolic BP may be falsely high.

Question 4

The nurse is performing a general survey on a patient.Which of the following findings 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 5

A nurse is helping at a health fair at a local mall.When measuring BPs in a variety of people,the nurse keeps in mind that:

Accepted Answer

A) after menopause,BP in women is usually lower than in men. 
B) an adult of African descent often has a higher BP than an adult of European descent who is the same age. 
C) BP measurements in overweight people should be the same as in those of normal weight. 
D) a teen's BP reading will be lower than that of an adult. 
A) after menopause,BP in women is usually lower than in men. 
B) an adult of African descent often has a higher BP than an adult of European descent who is the same age. 
C) BP measurements in overweight people should be the same as in those of normal weight. 
D) a teen's BP reading will be lower than that of an adult.

Question 6

The nurse knows that one advantage of the tympanic membrane thermometer (TMT)is that:

Accepted Answer

A) the rapid measuring is useful in uncooperative younger children. 
B) it is the most accurate method for measuring temperature in newborn infants. 
C) it is an inexpensive means of measuring temperature. 
D) studies strongly support use of the tympanic route in children under age 6 years. 
A) the rapid measuring is useful in uncooperative younger children. 
B) it is the most accurate method for measuring temperature in newborn infants. 
C) it is an inexpensive means of measuring temperature. 
D) studies strongly support use of the tympanic route in children under age 6 years.

Question 7

Which of the following statements about taking an axillary temperature is true?

Accepted Answer

A) A stable axillary temperature will register after 3 minutes. 
B) The accuracy and reliability of this method are well established. 
C) Its results are closer to the core temperature than the inguinal method. 
D) The axillary method is safer and more accessible than the rectal method. 
A) A stable axillary temperature will register after 3 minutes. 
B) The accuracy and reliability of this method are well established. 
C) Its results are closer to the core temperature than the inguinal method. 
D) The axillary method is safer and more accessible than the rectal method.

Question 8

A 70-year-old man has a BP of 150/90 mm Hg in the lying position,130/80 mm Hg in the sitting position,and 100/60 mm Hg in the 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 BP readings indicates orthostatic hypotension. 
C) The BP reading in the lying position is within normal limits. 
D) The change in BP 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 BP readings indicates orthostatic hypotension. 
C) The BP reading in the lying position is within normal limits. 
D) The change in BP reading is considered within normal limits for the patient's age.

Question 9

Which of the following statements about thigh pressure is true?

Accepted Answer

A) Auscultate either the popliteal or femoral vessels to obtain thigh pressure. 
B) The best patient position for measuring thigh pressure is the supine position with the knee slightly bent. 
C) If the BP in the arm is high in an adolescent,compare it with thigh pressure. 
D) Thigh pressure is lower than that in the arm because of the distance from the heart and the size of the popliteal vessels. 
A) Auscultate either the popliteal or femoral vessels to obtain thigh pressure. 
B) The best patient position for measuring thigh pressure is the supine position with the knee slightly bent. 
C) If the BP in the arm is high in an adolescent,compare it with thigh pressure. 
D) Thigh pressure is lower than that in the arm because of the distance from the heart and the size of the popliteal vessels.

Question 10

The nurse is preparing to measure the length,weight,and chest and head circumferences 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 the infant 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 infant's nose and cheekbones. 
A) length by using a tape measure. 
B) weight by placing the infant 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 infant's nose and cheekbones.

Question 11

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

Exam 10: General Survey, measurement, and Vital Signs

A patient's BP is 118/82 mm Hg.He asks the nurse to explain "what the numbers mean." The nurse's best reply would be:

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

What type of BP measurement error is most likely to occur if the examiner does not check for the presence of an auscultatory gap?

The nurse is performing a general survey on a patient.Which of the following findings is considered normal?

A nurse is helping at a health fair at a local mall.When measuring BPs in a variety of people,the nurse keeps in mind that:

The nurse knows that one advantage of the tympanic membrane thermometer (TMT)is that:

Which of the following statements about taking an axillary temperature is true?

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

Which of the following statements about thigh pressure is true?

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

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

Critical Thinking and Evidence-Informed Assessment

Health Promotion in the Context of Health Assessment

Cultural Competence: Cultural Care and Social Considerations in Health Assessment

The Interview

The Complete Health History

Mental Health Assessment

Substance Use in the Context of Health Assessment

Interpersonal Violence Assessment

Assessment Techniques and the Clinical Setting

Pain Assessment

Nutritional Assessment and Nursing Practice

Skin, hair, and Nails

Head and Neck, including Regional Lymphatic System

Eyes

Ears

Nose, mouth, and Throat

Breasts and Regional Lymphatic System

Thorax and Lungs

Heart and Neck Vessels

Peripheral Vascular System and Lymphatic System

Abdomen

Anus,rectum and Prostate

Musculoskeletal System

Neurological System

Male Genitourinary System

Female Genitourinary System

The Complete Health Assessment: Putting It All Together

Bedside Assessment of the Hospitalized Patient

Pregnancy

Functional Assessment of the Older Adult

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