Chapter 27: Complete Health Assessment, Vital signs Chapter 26 questions, Chapter 26 Measuring Vital Sign
A nurse receives information during shift report that a patient is afebrile. What action will the nurse take in response?
No action is necessary; this is a normal reading
A nurse participating in community blood pressure screening tells the patient their blood pressure is 120/80 mm Hg. When the patient asks what the numbers mean, what information does the nurse provide?
Normal blood pressure
A nurse is caring for a group of patients on a cardiac unit. Which finding will prompt the nurse to assess the apical-radial pulse?
Bounding radial pulse
A nurse is assessing the blood pressure of a patient with traumatic injuries using a Doppler device. Which information does the nurse expect to obtain?
Mean arterial blood pressure
A charge nurse working on a medical-surgical unit stops the AP from taking rectal temperatures on patients with which problems? Select all that apply.
Bradycardia Leukemia Thrombocytopenia
A nurse observes a nursing student is taking the blood pressure on a patient with a cuff that is too large for the patient's arm. What explanation does the nurse give to the student for why errors of measurement may result?
"Using the wrong cuff will result in an incorrect reading."
During the examination of a patient, the nurse notices that the patient has several small, flat macules on the posterior portion of her thorax. These macules are less than 1 cm wide. Another name for these macules is: A) warts. B) bullae. C) freckles. D) papules.
ANS: C) freckles A macule is solely a lesion with color change, flat and circumscribed, less than 1 cm. Macules are also known as freckles. See Chapter 12. Pages: 203-250
The nurse should use which location for eliciting deep tendon reflexes? A) Achilles B) Femoral C) Scapular D) Abdominal
ANS: A) Achilles Deep tendon reflexes are elicited in the biceps, triceps, brachioradialis, patella, and Achilles. Pages: 769-770
A female patient tells the nurse that she has four children and has had three pregnancies. How should the nurse document this? A) Gravida 3, para 4 B) Gravida 4, para 3 C) This information cannot be documented using the terms gravida and para. D) "The patient seems to be confused about how many times she has been pregnant."
ANS: A) Gravida 3, para 4 Gravida refers to the number of pregnancies, and para refers to the number of children. One pregnancy was with twins. Page: 781
A patient's uvula rises midline when she says "ahh" and she has a positive gag reflex. The nurse has just tested which cranial nerves? A) IX, X B) IX, XII C) X, XII D) XI, XII
ANS: A) IX, X Cranial nerves IX and X are being tested by having the patient say "ahh," noting the mobility of the uvula, and when assessing the patient's gag reflex. Page: 766
Which of these actions is most appropriate to perform on a 9-month-old infant at a well-child checkup? A) Testing for Ortolani's sign B) Assessment for stereognosis C) Blood pressure measurement D) Assessment for the presence of the startle reflex
ANS: A) Testing for Ortolani's sign Until the age of 12 months, the infant should be assessed for Ortolani's sign. If Ortolani's sign is present, it could indicate the presence of a dislocated hip. The other tests are not appropriate for a 9-month-old child. Pages: 565-620
During inspection of a patient's face, the nurse notices that the facial features are symmetric. This finding indicates that which cranial nerve is intact? A) VII B) IX C) XI D) XII
ANS: A) VII Cranial nerve VII is responsible for facial symmetry. Page: 766
After the health history has been obtained, and before beginning the physical examination, the nurse should ask the patient to first: A) empty the bladder. B) completely disrobe. C) lie on the examination table. D) walk around the room.
ANS: A) empty the bladder Before beginning the examination, the nurse should ask the person to empty the bladder (save the specimen if needed), disrobe except for underpants, put on a gown, and sit with legs dangling off side of the bed or table. Page: 764
The nurse is performing a vision examination. Which of these charts is most widely used for vision examinations? A) Snellen B) Shetllen C) Smoollen D) Schwellon
ANS: A) snellen The Snellen eye chart is most widely used for vision examinations. The other options are not tests for vision examinations. Page: 764
During an examination, the patient tells the nurse that she sometimes feels as if objects are spinning around her. The nurse would document that she occasionally experiences: A) vertigo. B) tinnitus. C) syncope. D) dizziness.
ANS: A) vertigo Vertigo is the sensation of moving around in space (subjective) or of having objects move about the person (objective) and is a result of a disturbance of equilibratory apparatus. See Chapter 23. Pages: 621-678
While recording in a patient's medical record, the nurse notices that a patient's Hematest results are positive. This means that there: A) are crystals in his urine. B) are parasites in his stool. C) is occult blood in his stool. D) are bacteria in his sputum.
ANS: C) is occult blood in his stool If a stool is Hematest positive, then it indicates the presence of occult blood. See Chapter 21. Pages: 527-564
Which of these statements is true regarding the recording of data from the history and physical examination? A) Use long, descriptive sentences to document findings. B) Record the data as soon as possible after the interview and physical examination. C) If the information is not documented, then it can be assumed that it was done as a standard of care. D) The examiner should avoid taking any notes during the history and examination because of the possibility of decreasing rapport with the patient.
ANS: B) Record the data as soon as possible after the interview and physical examination. The data from the history and physical examination should be recorded as soon after the event as possible. From a legal perspective, if it is not documented, it was not done. Brief notes should be taken during the examination. When documenting, the nurse should use short clear phrases and should avoid redundant phrases and descriptions. Page: 781
Which of these statements is true regarding the complete physical assessment? A) The male genitalia should be examined in the supine position. B) The patient should be in the sitting position for examination of the head and neck. C) The vital signs, height, and weight should be obtained at the end of the examination. D) To promote consistency between patients, the examiner should not vary the order of the assessment.
ANS: B) The patient should be in the sitting position for examination of the head and neck. The head and neck should be examined in the sitting position to best palpate the thyroid and lymph nodes. The male patient should stand during examination of the genitalia. Vital signs are measured early in the assessment. The sequence of the assessment may need to vary according to different patient situations. Page: 764
During a complete health assessment, how would the nurse test the patient's hearing? A) By observing how the patient participates in normal conversation B) Using the whispered voice test C) Using the Weber and Rinne tests D) Testing with an audiometer
ANS: B) Using the whispered voice test During the complete health assessment, the nurse should test hearing with the whispered voice test. The other options are not correct. Page: 765
During examination, the nurse finds that a patient is unable to distinguish objects placed in his hand. The nurse would document: A) stereognosis. B) astereognosis. C) graphesthesia. D) agraphesthesia.
ANS: B) astereognosis. Astereognosis is the inability to identify correctly an object placed in the hand. See Chapter 23. Pages: 621-678
A 5-year old child is in the clinic for a checkup. The nurse would expect him to: A) have to be held on his mother's lap. B) be able to sit on the examination table. C) be able to stand on the floor for the examination. D) be able to remain alone in the examination room
ANS: B) be able to sit on the examination table. At 4 or 5 years old, a child usually feels comfortable on the examination table. Older infants and young children aged 6 months to 2 or 3 years should be positioned in the parent's lap. Pages: 777-778
After the examination of an infant, the nurse documents opisthotonos. The nurse recognizes that this finding often occurs with: A) cerebral palsy. B) meningeal irritation. C) a lower motor neuron lesion. D) a upper motor neuron lesion.
ANS: B) meningeal irritation Opisthotonos is a form of spasm in which the head is arched back, and there is stiffness of the neck and extension of the arms and legs. It occurs with meningeal or brainstem irritation. See Chapter 23 Pages: 621-678
An 85-year-old man has come in for a physical examination, and the nurse notices that he uses a cane. When documenting general appearance, the nurse should document this information under the section that covers: A) posture. B) mobility. C) mood and affect. D) physical deformity.
ANS: B) mobility Use of assistive devices would be documented under the mobility section. The other responses are all other categories of the general appearance section of the health history. Page: 764
During inspection of the posterior chest, the nurse should assess for: A) symmetric expansion. B) symmetry of shoulders and muscles. C) tactile fremitus. D) diaphragmatic excursion.
ANS: B) symmetry of shoulders and muscles. During inspection of the posterior chest, the nurse should inspect for symmetry of shoulders and muscles, configuration of the thoracic cage, and skin characteristics. Symmetric expansion and tactile fremitus are assessed with palpation; diaphragmatic excursion is assessed with percussion. Page: 766
When assessing the neonate, the nurse should test for hip stability with which method? A) Eliciting the Moro reflex B) Performing the Romberg's test C) Checking for the Ortolani's sign D) Assessing the stepping reflex
ANS: C) Checking for the Ortolani's sign The nurse should test for hip stability in the neonate by testing for the Ortolani's sign. The other tests are not appropriate for testing hip stability. Pages: 775-776
The nurse will measure a patient's near vision with which tool? A) Snellen eye chart with letters B) Snellen "E" chart C) Jaeger card D) Ophthalmoscope
ANS: C) Jaeger card The Jaeger card is used to measure near vision. See Chapter 14. Pages: 279-322
The nurse should wear gloves for which of these examinations? A) Measuring vital signs B) Palpation of the sinuses C) Palpation of the mouth and tongue D) Inspection of the eye with an ophthalmoscope
ANS: C) Palpation of the mouth and tongue Gloves should be worn when the examiner is exposed to the patient's body fluids. Page: 766
A patient is unable to shrug her shoulders against the nurse's resistant hands. What cranial nerve is involved with successful shoulder shrugging? A) VII B) IX C) XI D) XII
ANS: C) XI Cranial nerve XI enables the patient to shrug her shoulders against resistance. Page: 766
The nurse notices that a patient has ulcerations on the tips of the toes and on the lateral aspect of the ankles. This finding indicates: A) lymphedema. B) Raynaud's disease. C) arterial insufficiency. D) venous insufficiency.
ANS: C) arterial insufficiency. Ulcerations on the tips of the toes and lateral aspect of the ankles are indicative of arterial insufficiency. See Chapter 20. Pages: 499-525
During an examination, the nurse notices that a patient's legs turn white when they are raised above the patient's head. The nurse should suspect: A) lymphedema. B) Raynaud's disease. C) chronic arterial insufficiency. D) chronic venous insufficiency.
ANS: C) chronic arterial insufficiency. Elevational pallor (marked) indicates arterial insufficiency. See Chapter 20. Pages: 499-525
A patient tells the nurse that "sometimes I wake up at night and I have real trouble breathing. I have to sit up in bed to get a good breath." When documenting this information, the nurse would note: A) orthopnea. B) acute emphysema. C) paroxysmal nocturnal dyspnea. D) acute shortness of breath episode.
ANS: C) paroxysmal nocturnal dyspnea Paroxysmal nocturnal dyspnea occurs when the patient awakens from sleep with shortness of breath and needs to be upright to achieve comfort. See Chapter 18. Pages: 411-454
The nurse has just recorded a positive obturator test on a patient who has abdominal pain. This test is used to confirm a(n): A) inflamed liver. B) perforated spleen. C) perforated appendix. D) enlarged gallbladder.
ANS: C) perforated appendix. A perforated appendix irritates the obturator muscle, producing pain. See Chapter 21. Pages: 527-564
When the nurse flexes the patient's knee and gently compresses the gastrocnemius muscle anteriorly against the tibia, the patient indicates that he is having calf pain. The nurse should document _____ sign. A) positive Allen's B) negative Allen's C) positive Homans' D) negative Homans'
ANS: C) positive Homan's Calf pain with these maneuvers is a positive Homans' sign, which occurs in some cases of deep vein thrombosis. See Chapter 20. Pages: 499-525
Which of these is included in assessment of general appearance? A) Height B) Weight C) Skin color D) Vital signs
ANS: C) skin color General appearance includes items such as level of consciousness, skin color, nutritional status, posture, mobility, facial expression, mood and affect, speech, hearing, and personal hygiene. Height, weight, and vital signs are considered measurements. Page: 764
If the nurse records the results to the Hirschberg test, the nurse has: A) tested the patellar reflex. B) assessed for appendicitis. C) tested the corneal light reflex. D) assessed for thrombophlebitis.
ANS: C) tested the corneal light reflex. The Hirschberg test assesses the corneal light reflex. See Chapter 14. Pages: 279-322
The nurse has just completed an examination of a patient's extraocular muscles. When documenting the findings, the nurse should document the assessment of which cranial nerves? A) II, III, VI B) II, IV, V C) III, IV, V D) III, IV, VI
ANS: D) III, IV, VI Extraocular muscles are innervated by cranial nerves III, IV, and VI. Page: 765
During an examination, the nurse notices that a patient is unable to stick out his tongue. Which cranial nerve is involved with successful performance of this action? A) I B) V C) XI D) XII
ANS: D) XII Cranial nerve XII enables the person to stick out his or her tongue. Page: 766
During an examination, a patient has just successfully completed the finger-to-nose and the rapid-alternating-movements tests and is able to run each heel down the opposite shin. The nurse will conclude that the patient's ____ function is intact. A) occipital B) cerebral C) temporal D) cerebellar
ANS: D) cerebellar The nurse should test cerebellar function of the upper extremities by using the finger-to-nose test or rapid-alternating-movements test. The nurse should test cerebellar function of the lower extremities by asking the person to run each heel down the opposite shin. Pages: 769-770
The nurse documents that a patient has coarse, thickened skin and brown discoloration over the lower legs. Pulses are present. This finding is probably the result of: A) lymphedema. B) Raynaud's disease. C) chronic arterial insufficiency. D) chronic venous insufficiency.
ANS: D) chronic venous insufficiency. Chronic venous insufficiency would present as firm brawny edema, coarse thickened skin, normal pulses, and brown discoloration. See Chapter 20. Pages: 499-525
After assessing a female patient, the nurse notices flesh-colored, soft, pointed, moist, papules in a cauliflower-like patch around her introitus. This finding is most likely: A) urethral caruncle. B) syphilitic chancre. C) herpes. D) human papillomavirus.
ANS: D) human papillomavirus Human papillomavirus appears in a flesh-colored, soft, moist, cauliflower-like patch of papules. See Chapter 26. Pages: 725-762
The nurse is documenting the assessment of an infant. During the abdominal assessment, the nurse noticed a very loud splash auscultated over the upper abdomen when the nurse rocked her from side to side. This finding would indicate: A) epigastric hernia. B) pyloric obstruction. C) hypoactive bowel sounds. D) hyperactive bowel sounds.
ANS: D) hyperactive bowel sounds. A succussion splash, which is unrelated to peristalsis, is a very loud splash auscultated over the upper abdomen when the infant is rocked side to side. It indicates increased air and fluid in the stomach as seen with pyloric obstruction or large hiatus hernia. See Chapter 21. Pages: 527-564
A patient states, "Whenever I open my mouth real wide, I feel this popping sensation in front of my ears." To further examine this, the nurse would: A) place the stethoscope over the temporomandibular joint and listen for bruits. B) place the hands over his ears and ask him to open his mouth "really wide." C) place one hand on his forehead and the other on his jaw and ask him to try to open his mouth. D) place a finger on his temporomandibular joint and ask him to open and close his mouth.
ANS: D) place a finger on his temporomandibular joint and ask him to open and close his mouth. The nurse should palpate the temporomandibular joint by placing your fingers over it as the person opens and closes the mouth. Page: 765
While examining a 48-year-old patient's eyes, the nurse notices that he had to move the handheld vision screener farther away from his face. The nurse would suspect: A) myopia. B) omniopia. C) hyperopia. D) presbyopia.
ANS: D) presbyopia Presbyopia, the decrease in power of accommodation with aging, is suggested when the handheld vision screener card is moved farther away. See Chapter 14. Pages: 279-322
During the examination of a patient's mouth, the nurse observes a nodular bony ridge down the middle of the hard palate. The nurse would chart this finding as: A) cheilosis. B) leukoplakia. C) ankyloglossia. D) torus palatinus.
ANS: D) torus palatinus. A normal variation of the hard palate is a nodular bony ridge down the middle of the hard palate, a torus palatinus. See Chapter 16. Pages: 351-382
When the nurse performs the confrontation test, the nurse has assessed: A) extraocular eye muscles (EOMs). B) pupils (PERRLA). C) near vision. D) visual fields.
ANS: D) visual fields The confrontation test assesses visual fields. The other options are not tested with the confrontation test. Page: 765
For the abdominal assessment, place these assessment techniques in the correct order, with A being performed first and E being performed last. A. Deep palpation, all quadrants B. Light palpation, all quadrants C Auscultate bowel sounds D. Inspect abdomen for contour, skin characteristics, and pulsations E. Percuss all quadrants
ANS: D, C, E, B, A After inspection, first perform auscultation of bowel sounds so that the sounds are not altered by percussion and palpation. Follow auscultation by percussion, then light palpation, then deep palpation. See Chapter 21. Pages: 527-564
A nursing student is caring for a patient who has intravenous fluids infusing in the right arm. What action will the student take to correctly obtain the blood pressure?
Assess blood pressure using the left arm
A nurse is caring for a postoperative patient who experienced hypovolemic shock necessitating transfer to the ICU. The nurse manager reviews the medical record and suspects which situation contributed to the emergency? Exhibit: Electronic health record (EHR) Graphic sheet 2:00 PM T 99.2, P 88, RR 16, BP 106/54 2:15 PM T 99.6, P 94, RR 16, BP 100/52 2:30 PM T 99.4, P 110, RR 18, BP 96/50 2:45 PM T 99.2, P 120, RR 20, BP 84/48
Failing to report tachycardia and hypotension to the provider
A patient has a blood pressure reading of 130/90 mm Hg during a clinic visit. What recommendation for follow-up will the nurse make?
Follow-up measurements of blood pressure
A nurse is assessing the vital signs of a group of patients in the emergency department. Which patients require follow-up by the nurse? Select all that apply.
Infant whose temperature is 100.5°F (38.1°C) Adolescent whose pulse rate is 70 beats/min Adult whose respiratory rate is 20 breaths/min Older adult whose pulse rate is 42 beats/min
The nurse must assess a patient's blood pressure using a thigh cuff, due to presence of a right antecubital IV and a left arm dialysis access. Which of these arteries will the nurse use for auscultation?
Popliteal
During assessment of vital signs, a patient reports severe abdominal pain. Which pain-related changes in vital signs may be present? Select all that apply.
Pulse rate of 102 Blood pressure 154/86 Respiratory rate of 24
A nurse enters a room and finds a patient who is unable to catch their breath, has a respiratory rate of 28, and is using accessory muscles to breathe. What intervention will the nurse use to relieve dyspnea?
Raise the head of the bed
While taking an adult patient's pulse, a nurse obtains a heart rate of 140 beats/min. What should the nurse do next?
Report the rate to the health care provider
A nurse has assessed an older adult for orthostatic hypotension as shown in the electronic health record (EHR). What action will the nurse take? Exhibit: Electronic health record (EHR) Graphic sheet 8:00 AM BP lying 124/76 BP sitting 118/74 BP standing 98/58
Suggest that in the future the patient "dangle" for a few minutes before standing
A nurse is caring for a newborn with hypothermia. What action does the nurse take to prevent heat loss from convection?
Wrapping the newborn in a blanket
Which do you report to the nurse at once? a) an adullt has a pulse of 124 beats per min b) an adult has a pulse of 90 beats per min c) an adult has a pulse of 86 beats per min d) an adult has a pulse of 64 beats per min
a) an adult has a pulse of 124 beats per minutes
A rectal temperature is taken when the person a) is unconscious b) has heart disease c) is confused d) has diarrhea
a) is unconscious
Which is usually used to take an adult's pulse? a) the radial pulse b) the apical pulse c) the apical-radial pulse d) the brachial pulse
a) the radial pulse
When measuring BP, you should do the following except a) use the arm with an IV infusion b) apply the cuff to a bare upper arm c) turn off the TV d) locate the brachial artery
a) use the arm with an IV infusion
In an adult, normal respiration are a) 10 to 18 per minutes b) 12 to 20 per minutes c) less than 20 per minute d) more than 20 per minute
b) 12 to 20 per minute
Which should you report at once? a) an oral temperature at 98.4 f b) a rectal temperature of 101 F c) an axillary temperature of 97.6 F d) an oral temperature of 99.0 F
b) a rectal temperature of 101.1 F
Respirations are usually counted a) after taking the temperature b) after taking the pulse c) before taking the pulse d) after taking the blood pressure
b) after taking the pulse
You are not sure of hearing an accurate BP measurement. What should you do? a) record what you think that you heard b) measure the BP again after 60 seconds c) use the bell part of the stethoscope d) ask another nursing assistant to take the BP
b) measure the BP again after 60 seconds
Which site is used to take an infant's temperature? a) oral site b) rectal site c) axillary site d) tympanic membrane site
b) rectal site
Which statement about the apical radial pulse is true? a) the radial pulse can be greater than the apical pulse b) the apical pulse can be greater than the radial pulse c) the apical and radial pulses are always equal d) the pulse deficit is always 0
b) the apical pulse can be greater than the radial pulse
The systolic pressure is the point a) Where the pulse is no longer felt b) where the first sound is heard where the last sound is heard d) 30 mm hg above where the pulse was felt
b) where the first sound is heard
Normal respirations a) are heard as the person exhales b) are heard as the person exhales c) are quiet d) sound like wheezing with inhalation and exhalation
c) are quiet
Which gives the least accurate measurement of body temperature? a) oral site b) rectal site c) axillary site d) tympanic membrane site
c) axillary site
Which statement is false: a) the vital signs are temperature,pulse,respiration and blood pressure b) vital signs detect changes in body function c) vital signs change only during illness d) sleep, exercise, drugs,emotion and noise affect vital signs
c) vital signs change only during illness
Which blood pressure is normal for an adult? a) 88/54 mm hg b) 140/90 mm hg c) 100/58 mm hg d) 112/78 mm hg
d) 112/78 mm hg
