Deck 6: General Survey and Assessing Vital Signs

Question 1

All of the following equipment is used to perform a physical health assessment EXCEPT:

A) A sphygmomanometer.
B) A watch with a second hand.
C) A stethoscope.
D) A body mass index (BMI) chart.

Answer 1

A body mass index (BMI) chart.

Question 2

Which of the following is the correct sequence in which to perform a physical assessment?

A) General survey, temperature, pulse, respiratory rate, blood pressure
B) Respiratory rate, blood pressure, general survey, pulse, temperature
C) Respiratory rate, general survey, pulse, blood pressure, temperature
D) Blood pressure, respiratory rate, general survey, temperature, pulse

Answer 2

General survey, temperature, pulse, respiratory rate, blood pressure

Question 3

A nurse is performing a general survey on a patient in preparation for performing a physical examination. The nurse understands it is important to take cultural considerations into account for each individual patient because:

A) Nurses do not have to understand different cultures. It is more important to treat all patients the same.
B) It is important for the nurse to understand cultural norms for individual cultures to provide the best care.
C) Patients will tell nurses if there are any cultural considerations that need to be respected during their care.
D) Nurses have heavy workloads and their focus is on patient care. They do their best to understand cultural norms.

Answer 3

It is important for the nurse to understand cultural norms for individual cultures to provide the best care.

Question 4

A nurse is performing a physical assessment on a patient as part of an annual physical. The nurse understands that the body temperature:

A) Varies with the time of day and the site of measurement.
B) Should not vary and variation can indicate illness.
C) Can be measured in several sites and the temperature should be the same in all sites.
D) Is not a vital sign and is not part of the physical assessment.

Question 5

During a physical assessment of a patient, the nurse recognizes that all of the following are considered abnormal findings EXCEPT

A) unkempt grooming.
B) the patient is cachectic.
C) odors of the body or breath.
D) the patient appears to be stated age.

Question 6

A nurse is preparing a patient for a vital sign assessment. Which of the following questions should the nurse ask prior to taking the vital signs?

A) "Have you eaten any salty foods today?"
B) "Do you have any allergies, and if so, what type of reaction?"
C) "Have you had any caffeine or smoked in the past 30 minutes?"
D) "Have you exercised today?"

Question 7

A nurse is preparing to auscultate an apical heart rate on a patient as part of a vital sign assessment. The nurse knows the proper order to assess the apical heart rate is which of the following?

A) Uncover left side of chest, place diaphragm of stethoscope over left fifth intercostal space at midclavicular line, warm stethoscope, auscultate heartbeat, count beats for 30 seconds (multiply ? 2), clean stethoscope with alcohol, explain technique.
B) Explain technique, place diaphragm of stethoscope over clothes over left fifth intercostal space at midclavicular line, auscultate heartbeat, count beats for 30 seconds (multiply ? 2).
C) Explain technique, warm stethoscope, uncover left side of chest, place diaphragm of stethoscope over right fifth intercostal space at midclavicular line, count beats for 30 seconds (multiply ? 2), clean stethoscope with alcohol.
D) Explain technique, warm stethoscope, uncover left side of chest, place diaphragm of stethoscope over left fifth intercostal space at midclavicular line, auscultate heartbeat, count beats for 60 seconds, clean stethoscope with alcohol.

Question 8

Blood pressure is measured routinely as part of the vital sign assessment. The best sites that a blood pressure can be taken include all of the following EXCEPT

A) the ankle.
B) the upper arm.
C) the forearms.
D) the thigh.

Question 9

To obtain an accurate blood pressure, the blood pressure cuff needs to fit the patient properly. A nurse assessing a patient knows that a proper fitting blood pressure cuff should cover________ of the distance from the patient's elbow to the shoulder.

A) two-thirds
B) one-half
C) three-fourths
D) one-third

Question 10

The nurse is instrumental in collecting data during a health assessment. The first steps in performing a physical assessment are

A) height and weight.
B) general survey and vital signs.
C) nutritional assessment.
D) past medical history.

Question 11

A nurse is assessing whether a patient is alert and oriented as part of assessing the patient's level of consciousness (LOC). The nurse knows that all of the following are checked to see if a patient is alert and oriented as part of the LOC assessment EXCEPT

A) time.
B) place.
C) speech.
D) person.

Question 12

A nurse is preparing to take an oral temperature on a patient. The nurse understands that the patient needs to wait 30 minutes to take an oral temperature if the patient

A) understands and follows directions.
B) is able to breathe through the nose.
C) has an altered mental status.
D) has had hot or cold food or drink in the last 30 minutes.

Question 13

A patient arrives for a physical assessment and is complaining of not feeling well. The nurse begins with a general survey and assessing vital signs. The nurse is concerned that the patient has orthostatic hypotension due to the patient complaining of

A) alteration in mental status and forgetfulness.
B) dizziness and feeling lightheaded with position changes.
C) gastrointestinal upset, nausea, and vomiting.
D) feeling cold, weak, and shivering.

Question 14

A patient arrives at the clinic complaining of a severe headache and nausea. The nurse begins with the general survey and assesses the vital signs. The nurse understands that the patient is in hypertensive crisis, which is a medical emergency, because his blood pressure is within which of the following parameters?

A) Systolic greater than 180 or diastolic greater than 110
B) Systolic greater than 160 or diastolic greater than 100
C) Systolic 140 to 159 or diastolic 90 to 99
D) Systolic 120 to 139 or diastolic 80 to 89

Question 15

When assessing a patient's vital signs, a nurse understands that an essential principle of vital sign assessment is

A) retaking the vital signs if the first set is not within normal range.
B) comparing a patient's baseline or prior vital signs to the current reading.
C) asking the patient if he or she remembers the last set of vital signs.
D) there is no need to compare current vital signs to previous vital signs.

Question 16

A patient arrives for a health assessment and the nurse notes the patient has a heavy foreign accent. The nurse knows the best action is

A) to call for an interpreter to interpret for the patient.
B) use a family member as an interpreter for the patient.
C) ask the patient if he or she understands and speaks English.
D) assume the patient understands and speaks English.

Question 17

A female patient, age 48, comes to the clinic with complaints of dizziness and a frontal headache. She tells you she is under a lot of stress because her husband was recently laid off. She is 5'4" and weighs 150 lb. You take her blood pressure and it is 178/100. When you tell her the blood pressure reading she says, "This cannot be right! I usually run 100/60." What should be your next action?

A) Tell the patient that stress can raise blood pressure.
B) Wait 2 minutes and retake the blood pressure in the other arm.
C) Call in the health-care provider to retake the blood pressure.
D) Document the blood pressure as high.

Question 18

You are caring for a patient with traumatic brain injury. The health-care provider has ordered rectal temperatures daily. How far should you insert the rectal probe into the anal canal?

A) About 0.50 inch
B) About 0.75 inch
C) About 1.0 inch
D) About 1.5 inches

Question 19

You are assessing a 78-year-old hospice patient who has end stage lung cancer. Which of the following findings would indicate an acute decline in the patient's health status?

A) Temporal temperature 99.8°F, pulse 82, irregular, amplitude +2, RR 22
B) Temporal temperature 100.8°F, pulse 90, regular, amplitude 2+, RR 20
C) Tympanic temperature 100.1°F, pulse 60, irregular, amplitude 3+, RR 18
D) Tympanic temperature 97°F, pulse 106, irregular, amplitude 1+, RR 26

Question 20

A 23-year-old client is being seen at the university health clinic for chest pain. The nurse has gathered the following assessment data: temperature 99.2°F (tympanic), pulse 90 (apical), regular respirations 28, blood pressure 144/84 (left arm). Which assessment data should be of greatest concern to the nurse?

A) Temperature of 99.2°F
B) Pulse 90
C) Respirations 28
D) Blood pressure 144/84

Question 21

Mary Jane is getting a physical examination prior to starting her new job. You take her vital signs: temperature (97.8°F), radial pulse 92 reg, + 2 amplitude, respiratory rate (20), and blood pressure 150/96. What is the category of Mary's blood pressure?

A) Normal
B) Prehypertension
C) Stage 1 Hypertension
D) Stage 2 Hypertension

Question 22

An 88-year-old patient had a warm sponge bath 10 minutes ago and a cup of hot tea 5 minutes ago. The nurse needs to assess her body temperature. Which temperature method should the nurse use to assess her temperature?

A) Oral
B) Rectum
C) Axillary
D) Tympanic

Question 23

You are performing a respiratory assessment on a male patient who has smoked for the past 30 years. You are having difficulty counting his respirations. Which of the following actions would be most appropriate?

A) Place the diaphragm of the stethoscope over the trachea.
B) Place the bell of the stethoscope below the clavicle.
C) Encourage the patient to take deep breaths.
D) Stand behind the patient to assess respirations.

Question 24

You are performing the general survey as part of the physical assessment. Which of the following observations are considered part of the general survey? Select all that apply.

A) Body structure
B) Patient's hygiene
C) Vital signs
D) Appears stated age
E) Appears healthy

Question 25

Normal vital signs change with age, sex, weight, exercise tolerance, and medical condition. Which of the following are classified as vital signs? Select all that apply.

A) Pulse
B) Temperature
C) Heart rate
D) Respiratory rate
E) Weight

Question 26

Measuring a patient's body temperature is part of routine essential nursing care and can be taken in several different ways. The site and measuring device is chosen based on a number of factors including which of the following? Select all that apply.

A) Patient preference
B) Age of patient
C) Mental status and cognition
D) Physical condition of patient
E) Safety and nurse's technique with using device

Question 27

Rectal temperatures are considered to be an accurate route for measuring core temperature. Rectal temperatures are contraindicated in which of the following patients? Select all that apply.

A) Patients who have had rectal surgery
B) Patients with cardiac disease
C) Patients with diarrhea
D) Patients who refuse a rectal temperature
E) Patients who are immobile

Question 28

A nurse is assessing a radial pulse. What characteristics of the pulse must be documented? Select all that apply.

A) Time taken
B) Pulse site
C) Pulse rate
D) Pulse rhythm
E) Pulse amplitude

Question 29

During a health assessment of a patient, a nurse is assessing vital signs, including respiratory rate. She knows that several factors can influence the respiratory rate including which of the following? Select all that apply.

A) exercise.
B) medication.
C) pain.
D) stress.
E) fever.

Question 30

A nurse is performing a vital sign assessment on a patient and understands that he must observe the following characteristics to assess a patient's breathing. Select all that apply.

A) Rate
B) Depth
C) Skin movement
D) Rhythm
E) Effort

Question 31

Hypertension is a growing health problem in the United States. The main factors that contribute to the increase in the number of patients with hypertension include which of the following? Select all that apply.

A) The obesity epidemic
B) Population growth
C) Genetics
D) Anxiety
E) The aging population

Question 32

High blood pressure is a modifiable risk factor for heart disease and stroke. Nurses are responsible for educating patients about lifestyle modifications for high blood pressure, which include which of the following? Select all that apply.

A) Reducing sodium, saturated fats, and cholesterol.
B) Quitting cigarette smoking.
C) Limiting alcohol intake.
D) Genetic testing.
E) If overweight, losing weight.

Question 33

A patient arrives for a health assessment and has poor hygiene, body odor, and clothes that are too big and unkempt. The nurse is concerned and considers which of the following reasons for the patient's condition? Select all that apply.

A) Lack of resources
B) Frugality
C) Impaired mental status or cognitive dysfunction
D) Lack of finances
E) A dislike for shopping

Question 34

You are assessing a 60-year-old patient's blood pressure. You hear the systolic reading at 164. The Korotkoff sounds fade out at 130 and resume at 108. You hear the last Korotkoff sound at 82. This fading of sounds is called a[n] ________________ ________________.

Question 35

You are preparing to assess the blood pressure. You start by wrapping the deflated cuff around the patient's arm about ___________ inch(es) above the brachial artery.

Question 36

You are assessing the radial pulse and determine that it is 92 and irregular. You auscultate the apical pulse at 104 and irregular. What is the pulse deficit? ___________

Question 37

A normal resting pulse for a well-conditioned athlete is __________ to __________ beats per minute.

Question 38

Normal respirations are ________ to _________ breaths per minute.

Question 39

In a normotensive (normal BP) blood pressure reading, the systolic reading is less than _________ and the diastolic reading is less than __________.

Question 40

Hypertension is blood pressure reading greater than _________ or the diastolic reading greater than ________.

Question 41

The ____________________ pulse is the most reliable and accurate location to assess the heart rate.