Deck 10: General Survey, Measurement, Vital Signs

Question 1

The nurse is performing a general survey.The nurse:

A)Observes the patient's body stature and nutritional status.
B)Interprets the subjective information the patient has reported.
C)Measures the patient's temperature, pulse, respirations, and blood pressure.
D)Observes specific body systems while performing the physical assessment.

Answer 1

Observes the patient's body stature and nutritional status.

Question 2

The nurse is examining a patient who is sweaty and complaining of "feeling cold." The nurse recognizes that the patient is losing heat through:

A)Exercise.
B)Evaporation.
C)Metabolism.
D)Food digestion.

Answer 2

Evaporation.

Question 3

The nurse assesses a 1-month-old infant to have a head measurement of 34 cm and a chest circumference of 32 cm.The nurse will:

A)Refer the infant to a physician for further evaluation.
B)Document the findings as normal for a 1-month-old infant.
C)Request that another nurse recheck the findings.
D)Ask the parent to return in 2 weeks to re-evaluate the head and chest circumferences.

Answer 3

Document the findings as normal for a 1-month-old infant.

Question 4

When measuring a patient's weight, the nurse will:

A)Weigh the patient wearing only undergarments.
B)Aim for similar daily weights regardless of type of scale used.
C)Allow the patient to keep the jacket and shoes on as long as these are documented next to the weight.
D)Weigh the patient at the same time daily for a sequence of weights.

Question 5

When assessing an older adult, which vital sign changes occur with aging?

A)Increase in pulse rate
B)Widened pulse pressure
C)Increase in body temperature
D)Decrease in diastolic blood pressure

Question 6

The nurse decides to use the temporal artery thermometer (TAT) with the 4-year-old patient because it is:

A)A useful rapid measurement for younger children.
B)The most accurate method for measuring body temperature in newborn infants.
C)The least expensive method of measuring temperature.
D)Well-supported by evidence for measuring temperature with children under age 6 years.

Question 7

Which of these actions illustrates the correct technique the nurse should use when assessing oral temperature with a mercury thermometer?

A)Waiting 30 minutes if the patient has ingested hot or iced liquids
B)Leaving the thermometer in place 3 to 4 minutes if the patient is afebrile
C)Placing the thermometer in front of the tongue and asking the patient to close the lips.
D)Shaking the mercury-in-glass thermometer down to below 36.6°C before taking the temperature.

Question 8

When assessing a patient's pulse, the nurse will also assess:

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

Question 9

A patient takes weekly home blood pressure readings, with average reading being 126/82 mm Hg.The nurse recognizes that the patient:

A)Has hypertension.
B)Is normotensive.
C)Needs to increase exercise for weight loss.
D)Needs to decrease alcohol intake.

Question 10

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.The nurse:

A)Assumes that the patient is eager and interested in participating in the interview.
B)Evaluates the patient for abdominal pain, which may be exacerbated in the sitting position.
C)Assumes that the patient is having difficulty breathing and assists him to the supine position.
D)Recognizes that a tripod position is often used when a patient is having respiratory difficulties.

Question 11

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 past 6 weeks.The nurse knows that:

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

Question 12

The nurse measures the patient's temperature to be 37.3°C during the afternoon.After comparing with the morning temperature of 36°C, the nurse:

A)Informs the physician that the patient has a temperature.
B)Recognizes that the patient's emotions are influencing her temperature.
C)Documents the temperature as a normal finding.
D)Is concerned that the patient is too cold.

Question 13

The nurse should measure rectal temperatures in which of these patients?

A)School-age child
B)Older adult
C)Comatose adult
D)Patient receiving oxygen by nasal cannula

Question 14

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

Question 15

When evaluating the temperature of older adults, the nurse knows that:

A)The body temperature of the older adult is lower than that of a younger adult.
B)An older adult's body temperature is approximately the same as that of a young child.
C)Body temperature depends on the type of thermometer used.
D)In the older adult, the body temperature varies widely because of less effective heat control mechanisms.

Question 16

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

A)Use a lubricated cover over a blunt tip electronic 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 17

While examining a 7-year-old patient, the nurse uses physical growth as the best index of the child's:

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

Question 18

The nurse is taking temperatures in a clinic with a tympanic membrane thermometer (TMT).Which statement is true regarding use of the TMT?

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

Question 19

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 on the thighs and lower legs
C)Presence of kyphosis and flexion in the knees and hips
D)Change in overall body proportion, including a longer trunk and shorter extremities

Question 20

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

A)1 minute, if the rhythm is irregular.
B)15 seconds and then multiply by 4, if the rhythm is regular.
C)2 full minutes to detect any variation in amplitude.
D)10 seconds and then multiply by 6, if the patient has no history of cardiac abnormalities.

Question 21

A student is late for his appointment and has rushed across campus to the health clinic.The nurse should:

A)Allow 5 minutes for him to relax and rest before checking his vital signs.
B)Check the blood pressure in both arms, expecting a difference in the readings because of his recent exercise.
C)Immediately monitor his vital signs on his arrival at the clinic and then 5 minutes later, recording any differences.
D)Check blood pressure with the student in the supine position, which will allow him to relax and will help obtain a more accurate reading.

Question 22

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

A)These readings are a normal response and attributable 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 readings is considered within normal limits for the patient's age.

Question 23

The nurse has collected the following information on a patient: palpated blood pressure-180 mm Hg; auscultated blood pressure-170/100 mm Hg; apical pulse-60 beats per minute; radial pulse-70 beats per minute.What is the patient's pulse pressure?

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

Question 24

When assessing the force, or strength, of a pulse, the nurse recalls that the pulse:

A)Is usually recorded on a 0-2-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 25

When auscultating the blood pressure of a 25-year-old patient, the nurse notices that phase I Korotkoff's sounds begin at 200 mm Hg.At 100 mm Hg, Korotkoff's sounds are muffled.At 92 mm Hg, Korotkoff's sounds disappear.How should the nurse record this patient's blood pressure?

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

Question 26

The nurse notices that a colleague is preparing to check the blood pressure of a patient who is obese by using a standard-sized blood pressure cuff.The nurse should expect the reading to:

A)Yield a falsely low blood pressure.
B)Yield a falsely high blood pressure.
C)Be the same, regardless of cuff size.
D)Vary as a result of the technique of the person performing the assessment.

Question 27

A patient is seen in the clinic for complaints of "fainting episodes that started last week." How should the nurse proceed with the examination?

A)Blood pressure readings are taken in both the arms and the thighs.
B)The patient is assisted to the lying position, and his blood pressure is taken.
C)His blood pressure is recorded in the lying, sitting, and standing positions.
D)His blood pressure is recorded in the lying and sitting positions; these numbers are then averaged to obtain a mean blood pressure.

Question 28

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

A)More clearly hear Korotkoff's sounds.
B)Detect the presence of an auscultatory gap.
C)Avoid missing a falsely elevated blood pressure.
D)More readily identify phase IV of Korotkoff's sounds.

Question 29

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

A)The infant's radial pulse should be palpated, and the nurse should observe any fluctuations resulting from activity or exercise.
B)The nurse should auscultate an apical rate for 1 minute and then assess for any normal irregularities, such as sinus arrhythmia.
C)The infant's blood pressure should be assessed by using a stethoscope with a large diaphragm piece to hear soft, muffled Korotkoff's sounds.
D)The infant's chest should be observed and the respiratory rate counted for 1 minute; the respiratory pattern may vary significantly.

Question 30

The nurse is preparing to measure the vital signs of a 6-month-old infant.Which action by the nurse is correct?

A)Respirations are measured, followed by pulse and temperature.
B)Vital signs should be measured more frequently than in an adult.
C)Procedures are explained to the parent, and the infant is encouraged to handle the equipment.
D)The nurse should first perform the physical examination to familiarize the infant and then measure the infant's vital signs.

Question 31

A patient's blood pressure is 118/82 mm Hg.He asks the nurse, "What do the numbers mean?" The nurse's best reply is:

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

Question 32

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

A)The cuff should be placed on the patient's arm and inflated 30 mm Hg above the patient's pulse rate.
B)The cuff should be inflated to 200 mm Hg in an attempt to obtain the most accurate systolic reading.
C)The cuff should be inflated 30 mm Hg above the point at which the palpated pulse disappears.
D)After confirming the patient's previous blood pressure readings, the cuff should be inflated 30 mm Hg above the highest systolic reading recorded.

Question 33

A nurse is helping at a health fair at the local mall.When taking blood pressures on a variety of people, the nurse keeps in mind that:

A)After menopause, blood pressure readings in women are usually lower than those in men.
B)The blood pressure of an adult of African descent is usually higher than that of an adult of European descent and of the same age.
C)Blood pressure measurements in people who are overweight should be the same as those of people who are at a normal weight.
D)A teenager's blood pressure reading will be lower than that of an adult.

Question 34

In a patient with acromegaly, the nurse will expect to discover which assessment findings?

A)Heavy, flattened facial features
B)Growth retardation and 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 35

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)Respirations should be counted for 1 full minute, noticing rate and rhythm.
B)Child's pulse and respirations should be simultaneously checked for 30 seconds.
C)Child's respirations should be checked for a minimum of 5 minutes to identify any variations in his or her respiratory pattern.
D)Patient's respirations should be counted for 15 seconds and then multiplied by 4 to obtain the number of respirations per minute.

Question 36

The nurse is conducting a health fair for older adults.Which statement is true regarding vital sign measurements in aging adults?

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 the systolic and diastolic blood pressures.
D)Changes in the body's temperature regulatory mechanism are more likely to cause fever to develop in the older person.

Question 37

The nurse is assessing the vital signs of a 20-year-old male marathon runner and documents the following vital signs: temperature-36°C; pulse-48 beats per minute; respirations-14 breaths per minute; blood pressure-104/68 mm Hg.Which statement is true concerning these results?

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 these readings, the patient should return to the clinic in 1 week.

Question 38

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

A)Immediately notify the physician.
B)Consider this finding normal 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 39

While measuring a patient's blood pressure, the nurse recalls that certain factors, such as _________________, help determine blood pressure.

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

Question 40

The nurse is helping another nurse to take a blood pressure reading on a patient's thigh.Which action is correct regarding thigh pressure?

A)Either the popliteal or femoral vessels should be auscultated to obtain the thigh blood pressure.
B)The best position to measure thigh blood pressure is the supine position with the knee slightly bent.
C)If the arm blood pressure is high in an adolescent, then it should be compared with the thigh blood pressure.
D)The thigh blood pressure is lower than the arm blood pressure, which is attributable to the distance away from the heart and the size of the popliteal vessels.

Question 41

A 75-year-old man with a history of hypertension was recently changed to a new antihypertensive drug.He reports feeling dizzy at times.How should the nurse evaluate his blood pressure?

A)Blood pressure and pulse should be recorded in the supine, sitting, and standing positions.
B)The patient should be directed to walk around the room and his blood pressure assessed after this activity.
C)Blood pressure and pulse are assessed at the beginning and at the end of the examination.
D)Blood pressure is taken on the right arm and then 5 minutes later on the left arm.

Question 42

The nurse is counting an infant's respirations.Which technique is correct?

A)Watching the chest rise and fall
B)Watching the abdomen for movement
C)Placing a hand across the infant's chest
D)Using a stethoscope to listen to the breath sounds

Question 43

The nurse is performing a general survey of a patient.Which finding 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 the patient's height.

Question 44

Which of these 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 45

The nurse is assessing children in a pediatric clinic.Which statement is true regarding the measurement of blood pressure in children?

A)Blood pressure guidelines for children are based on age.
B)Phase II Korotkoff's sounds are the best indicator of systolic blood pressure in children.
C)Using a Doppler device is recommended for accurate blood pressure measurements until adolescence.
D)The disappearance of phase V Korotkoff's sounds can be used for the diastolic reading in children.

Question 46

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

A)Diastolic blood pressure may not be heard.
B)Diastolic blood pressure may be falsely low.
C)Systolic blood pressure may be falsely low.
D)Systolic blood pressure may be falsely high.

Question 47

When considering the concepts related to blood pressure, the nurse knows that the concept of mean arterial pressure (MAP) is best described by which statement?

A)MAP is the pressure of the arterial pulse.
B)MAP reflects the stroke volume of the heart.
C)MAP is the pressure forcing blood into the tissues, averaged over the cardiac cycle.
D)MAP is an average of the systolic and diastolic blood pressures and reflects tissue perfusion.

Question 48

When checking for proper blood pressure cuff size, which guideline is correct?

A)The standard cuff size is appropriate for all sizes.
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 49

What is the pulse pressure for a patient whose blood pressure is 158/96 mm Hg and pulse rate is 72 beats per minute?

Question 50

While measuring a patient's blood pressure, the nurse uses the proper technique to obtain an accurate reading.Which of these situations will result in a falsely high blood pressure reading? (Select all that apply.)

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

Question 51

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 has which condition?

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

Question 52

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 have?

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