Deck 9: General Survey and Measurement

Question 1

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

A) Body mass index (BMI) of 20
B) When standing, the patient's base is narrow.
C) The patient appears older than his stated age.
D) Arm span (fingertip to fingertip) is greater than the height.

Answer 1

Body mass index (BMI) of 20

Question 2

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 likely have?

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

Answer 2

Hypopituitary dwarfism

Question 3

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

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

Answer 3

Observing the patient's body stature and nutritional status

Question 4

The nurse is assessing an 80-year-old male patient. Which assessment findings would be considered normal?

A) Increase in body weight from his younger years
B) Additional deposits of fat in the cheeks and forearms
C) Presence of kyphosis and flexion in bilateral knees and hips
D) Change in overall body proportion, including a longer trunk and shorter extremities

Question 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, what action should the nurse take?

A) 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.

Question 6

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. How should the nurse interpret these findings?

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 7

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 likely has which condition?

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

Question 8

When performing an examination, the nurse should consider a child's physical growth to be the best indicator of which aspect of health?

A) General health
B) Genetic makeup
C) Nutritional status
D) Activity and exercise patterns

Question 9

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

A) Body mass index
B) Height and weight
C) Head circumference
D) Chest circumference

Question 10

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. Which is an appropriate rationale for this patient's weight loss?

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

Question 11

In a patient with acromegaly, which assessment finding will the nurse expect to find?

A) Sternal deformity and hyperextensible joints
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 12

Which of these guidelines should a nurse follow when measuring a patient's weight?

A) 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.

Question 13

The nurse is preparing to measure the length, weight, chest, and head circumference of a 6-month-old infant. Which measurement technique is correct?

A) Measuring the infant's 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