Deck 10: General Survey, measurement, and Vital Signs

Question 1

This is a 52-year-old patient's third visit for monitoring of his BP.His weekly BP readings over 2 months have ranged between 124/84 and 134/82 mm Hg,with an average reading of 128/82 mm Hg.Into which BP category does this BP fall?

A)Normal BP
B)Requires monthly monitoring
C)Potential for hypertension
D)Diagnosis of hypertension

Answer 1

Normal BP

Question 2

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

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

Answer 2

Radiation

Question 3

When assessing a patient's pulse,which of the following characteristics should the nurse note?

A)Force
B)Pallor
C)Capillary refill time
D)Timing in the cardiac cycle

Answer 3

Force

Question 4

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

A)Wait for 30 minutes if the patient has ingested hot or cold liquids.
B)Leave the thermometer in place for 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 36.6°C before taking the temperature.

Question 5

To accurately measure the rectal temperature in an adult,the nurse would:

A)use a lubricated blunt-tip thermometer.
B)insert the thermometer 5 to 7.5 cm (2 to 3 in. )into the rectum.
C)leave the thermometer in place for up to 8 minutes if the patient is febrile.
D)wait for 2 to 3 minutes if the patient has recently smoked a cigarette.

Question 6

When assessing an older adult,which of the following vital sign changes should be considered to occur with aging?

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

Question 7

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

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

Question 8

When assessing a 75-year-old patient with asthma,the nurse notes that he assumes the tripod position,leaning forward with arms braced on the chair.On the basis of this observation,the nurse would:

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 the tripod position is often used when a patient is experiencing respiratory difficulties.

Question 9

In which of the following patients should the nurse measure rectal temperatures?

A)A school-age child
B)An older adult
C)A comatose adult
D)A patient who is receiving oxygen through a nasal cannula

Question 10

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

A)for 1 minute if the rhythm is irregular.
B)for 15 seconds and multiply by four,if the rhythm is regular.
C)initially for a full 2 minutes to detect any variation in amplitude.
D)for 10 seconds and multiply by six,if the patient has no history of cardiac abnormalities.

Question 11

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

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 12

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

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

Question 13

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

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 14

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)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 15

When measuring the temperature of older adults,the nurse remembers that an older adult's body temperature:

A)is lower than that of a younger adult.
B)is about the same as that of a young child.
C)depends on the type of thermometer used.
D)varies widely because of less effective heat control mechanisms.

Question 16

When performing a general survey,the examiner is:

A)observing the patient's overall body structure and mobility.
B)interpreting the subjective information the patient has provided.
C)measuring the patient's temperature,pulse,respirations,and blood pressure (BP).
D)observing specific body systems while performing the physical assessment.

Question 17

A 60-year-old male patient has been treated for pneumonia for the past 6 weeks.He is in the clinic to check an "unexplained" weight loss of 4.5 kg (2 lb)over the last 6 weeks.The nurse knows that:

A)his weight loss is probably from unhealthy eating habits.
B)chronic diseases such as hypertension don't cause weight loss.
C)unexplained weight loss often accompanies short-term illnesses.
D)his weight loss is probably not the result of a mental dysfunction.

Question 18

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

A)The patient should always be weighed while wearing only his or her undergarments.
B)It does not matter what type of scale is used,as long as the weights remain constant every day.
C)The patient may be allowed to wear his or her jacket and shoes while being weighed as long as this is recorded next to the weight.
D)Try to weigh the patient around the same time every day when a series of weights has to be taken.

Question 19

Which of the following statements about use of the TMT is true?

A)Taking a tympanic temperature is more time-consuming than taking a rectal temperature.
B)The tympanic method is more invasive and uncomfortable than the oral method.
C)With the tympanic method,there is reduced risk of cross-contamination compared with the rectal route.
D)The tympanic membrane most accurately reflects the temperature in the ophthalmic artery.

Question 20

A 1-month-old infant has a head circumference of 34 cm (13.5 in. )and a chest circumference of 32 cm (12.5 in. ).The nurse would:

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 bring the infant back in 2 weeks to reevaluate the head and chest circumferences.

Question 21

Which of the following statements about vital sign measurements in older adults is true?

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 BPs.
D)Changes in the body's temperature regulatory mechanism leave the older adult more likely to develop a fever.

Question 22

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

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 23

A patient is at the clinic complaining of "fainting episodes that started last week." How should the nurse proceed with the examination?

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

Question 24

Which of the following statements about the force,or strength,of the pulse is true?

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

Question 25

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

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

Question 26

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:

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

Question 27

Which of the following factors helps determine BP?

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

Question 28

The nurse will perform palpation before auscultating for BP.The reason for this is to:

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

Question 29

Which of the following statements about thigh pressure is true?

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 30

When auscultating the BP of a 25-year-old,the nurse finds that the phase I Korotkoff's sounds begin at 200 mm Hg.At 100 mm Hg,the Korotkoff's sounds become muffled,and at 92 mm Hg,they disappear.How should the nurse record this patient's BP?

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

Question 31

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?

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 32

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:

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 33

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

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 BP cuff 30 mm Hg above the point at which the palpated pulse disappears.
D)Consider the patient's past BP readings,and inflate the cuff 30 mm Hg above the highest systolic reading recorded.

Question 34

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:

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 35

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

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.

Question 36

The nurse has collected the following information on a patient: BP 170/100 mm Hg;apical pulse 60 bpm;radial pulse 70 bpm.What is the patient's pulse pressure?

A)10
B)70
C)80
D)100

Question 37

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

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 38

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?

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.

Question 39

The nurse is assessing the vital signs of a 20-year-old marathon runner and documents the following vital signs: temperature 36°C;pulse 50 beats per minute (bpm);respirations 14 breaths per minute;BP 104/68 mm Hg.Which of the following statements about these results is true?

A)The patient is experiencing tachycardia.
B)These are normal vital signs for a healthy,athletic adult.
C)The patient's pulse rate is not normal;his physician should be notified.
D)On the basis of today's readings,the patient should return to the clinic in 1 week.

Question 40

The nurse notices that a colleague is about to check the BP of an obese patient with a standard-sized BP cuff.The nurse should expect the reading to:

A)yield a falsely low BP.
B)yield a falsely high BP.
C)be the same regardless of cuff size.
D)vary as a result of the technique of the person performing the assessment.

Question 41

Which of the following situations will result in a falsely high BP reading? (Select all that apply. )

A)The person supports his or her own arm during the BP reading.
B)The BP cuff is too narrow for the arm.
C)The arm is held above the level of the heart.
D)The cuff is wrapped too loosely around the arm.
E)The person is sitting with his or her legs crossed.
F)The nurse does not inflate the cuff adequately.

Question 42

Which of the following statements about measurement of BP is true?

A)The BP guidelines for children are based on age.
B)Phase II Korotkoff's sounds are the best indicator of systolic BP in children.
C)Use of Doppler device is recommended for accurate BP measurement in children until adolescence.
D)The disappearance of phase V Korotkoff's sounds can be used for the diastolic reading in children and adults.

Question 43

Which of the following is true about checking for proper BP cuff size?

A)The standard cuff size is appropriate for all persons.
B)The length of the rubber bladder should equal 80% of the 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 44

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

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 breath sounds.

Question 45

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

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

Question 46

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

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 47

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

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 48

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

A)It is the pressure of the arterial pulse.
B)It 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 BPs and reflects tissue perfusion.

Question 49

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

A)Assess BP and pulse with the patient in the supine,sitting,and standing positions.
B)Have him walk around the room,and assess his BP after the activity.
C)Assess BP and pulse at the beginning as well as at the end of the examination.
D)Take the BP on the right arm and then 5 minutes later on the left arm.

Question 50

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

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 51

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 and has bruises.Which of the following conditions does the nurse note in this patient?

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