Chapter 09: General Survey, Measurement, Vital Signs Jarvis: Physical Examination & Health Assessment
with every heart beat, the heart pumps an amount of blood into the aorta:
stroke volume -70 mL for adults
max pressure felt on the artery during left ventricular contraction
systolic pressure
Force of pulse @ 1+ Force of pulse @ 0
weak, thready 0- absent
BMI calculation??
weight/height(in) squared multiplied by703
10. 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
widened pulse pressure With aging, the nurse keeps in mind that the systolic blood pressure increases, leading to widened pulse pressure. With many older people, both the systolic and diastolic pressures increase. The pulse rate and temperature do not increase.
33. When auscultating the blood pressure of a 25-year-old patient, the nurse notices the phase I Korotkoff sounds begin at 200 mm Hg. At 100 mm Hg, the Korotkoff sounds muffle. At 92 mm Hg, the Korotkoff sounds disappear. How should the nurse record this patients blood pressure?
200/92 In adults, the last audible sound best indicates the diastolic pressure. When a variance is greater than 10 to 12 mm Hg between phases IV and V, both phases should be recorded along with the systolic reading (e.g., 142/98/80).
19. Which technique is correct when the nurse is assessing the radial pulse of a patient? The pulse is counted for:
30-second interval multiplied by 2 is the most accurate and efficient technique when heart rates are normal or rapid and when rhythms are regular. If the rhythm is irregular, then the pulse is counted for 1 full minute.
1. What is the pulse pressure for a patient whose blood pressure is 158/96 mm Hg and whose pulse rate is 72 beats per minute?
62
1. While measuring a patients 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: The person supports his or her own arm during the blood pressure reading The blood pressure cuff is too narrow for the extremity. The arm is held above level of the heart. The cuff is loosely wrapped around the arm. The person is sitting with his or her legs crossed. The nurse does not inflate the cuff high enough.
A, B, D,E
elastic, recoil resisting pressure the blood exerts constantly b/t each contraction:
diastolic pressure
39. 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 bodys temperature regulatory mechanism leave the older person more likely to develop a fever.
An increased respiratory rate and a shallower inspiratory phase are expected findings.
MAP is?
diastolic pressure plus 1/3 of the pulse pressure
41. The nurse is performing a general survey of a patient. Which finding is considered normal? a. When standing, the patients 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 patients height.
Arm span (fingertip to fingertip) equals the patients height.
the pulse pressure is the:
difference between systole and diastole
An 18-month-old child is brought into the clinic for a health screening visit. To assess the height of the child: A) Use a tape measure. B) Use a horizontal measure board. C) Have the child stand on the upright scale. D) Measure the arm span to estimate height
B
45. 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.
Blood pressure and pulse should be recorded in the supine, sitting, and standing positions. Orthostatic vital signs should be taken when the person is hypertensive or is taking antihypertensive medications
31. The nurse is taking an initial blood pressure reading on a 72-year-old patient with documented hypertension. How should the nurse proceed? a. Cuff should be placed on the patients arm and inflated 30 mm Hg above the patients pulse rate. b. Cuff should be inflated to 200 mm Hg in an attempt to obtain the most accurate systolic reading. c. Cuff should be inflated 30 mm Hg above the point at which the palpated pulse disappears. d. After confirming the patients previous blood pressure readings, the cuff should be inflated 30 mm Hg above the highest systolic reading recorded.
Cuff should be inflated 30 mm Hg above the point at which the palpated pulse disappears. To check for the presence of an auscultatory gap, the cuff should be inflated 20 to 30 mm Hg beyond the point at which the palpated pulse disappears.
50. 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?
Cushing syndrome is characterized by weight gain and edema with central trunk and cervical obesity (buffalo hump) and round plethoric face (moon face
30. The nurse will perform a palpated pressure before auscultating blood pressure. The reason for this is to: a. More clearly hear the Korotkoff sounds. b. Detect the presence of an auscultatory gap. c. Avoid missing a falsely elevated blood pressure. d. More readily identify phase IV of the Korotkoff sounds.
Detect the presence of an auscultatory gap Inflation of the cuff 20 to 30 mm Hg beyond the point at which a palpated pulse disappears will avoid missing an auscultatory gap, which is a period when the Korotkoff sounds disappear during auscultation.
34. 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 a 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.
His blood pressure is recorded in the lying, sitting, and standing positions.
47. 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?
Hypopituitary dwarfism is caused by a deficiency in growth hormone in childhood and results in a retardation of growth below the third percentile, delayed puberty, and other problems.
36. The nurse is helping another nurse to take a blood pressure reading on a patients thigh. Which action is correct regarding thigh pressure? a.Either the popliteal or femoral vessels should be auscultated to obtain a thigh pressure. b.The best position to measure thigh pressure is the supine position with the knee slightly bent. c.If the blood pressure in the arm is high in an adolescent, then it should be compared with the thigh pressure. d.The thigh pressure is lower than the pressure in the arm, which is attributable to the distance away from the heart and the size of the popliteal vessels.
If the blood pressure in the arm is high in an adolescent, then it should be compared with the thigh pressure. Generally, thigh pressure is higher than that of the arm; however, if coarctation of the artery is present, then arm pressures are higher than thigh pressures.
22. When assessing the force, or strength, of a pulse, the nurse recalls that the pulse: a. Is usually recorded on a 0- to 2-point scale. b. Demonstrates elasticity of the vessel wall. c. Is a reflection of the hearts stroke volume. d. Reflects the blood volume in the arteries during diastole.
Is a reflection of the hearts stroke volume. The heart pumps an amount of blood (the stroke volume) into the aorta. The force flares the arterial walls and generates a pressure wave, which is felt in the periphery as the pulse.
16. Which of these actions illustrates the correct technique the nurse should use when assessing oral temperature with a mercury thermometer? a. Wait 30 minutes if the patient has ingested hot or iced liquids. b. Leave the thermometer in place 3 to 4 minutes if the patient is afebrile. c. Place the thermometer in front of the tongue, and ask the patient to close his or her lips. d. Shake the mercury-in-glass thermometer down to below 36.6 C before taking the temperature.
Leave the thermometer in place 3 to 4 minutes if the patient is afebrile.
44. 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.
MAP is the pressure forcing blood into the tissues, averaged over the cardiac cycle.
Force of pulse @ 2+
Normal
21. 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 nurses next action would be to: a. Immediately notify the physician. b. Consider this finding normal in children and young adults. c. Check the childs blood pressure, and note any variation with respiration. d. Document that this child has bradycardia, and continue with the assessment.
Normal-sinus arrhythmia is commonly found in children and young adults. During the respiratory cycle, the heart rate varies, speeding up at the peak of inspiration and slowing to normal with expiration.
1. The nurse is performing a general survey. Which action is a component of the general survey? a. Observing the patients body stature and nutritional status b. Interpreting the subjective information the patient has reported c. Measuring the patients temperature, pulse, respirations, and blood pressure d. Observing specific body systems while performing the physical assessment
Observing the patients body stature and nutritional status The general survey is a study of the whole person that includes observing the patients physical appearance, body structure, mobility, and behavior.
35. 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?
Orthostatic hypotension a drop in systolic pressure of more than 20 mm Hg, which occurs with a quick change to a standing position. Aging people have the greatest risk of this problem.
40. In a patient with acromegaly, the nurse will expect to discover which assessment findings?
Overgrowth of bone in the face, head, hands, and feet
26. While measuring a patients 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
Peripheral vascular resistance The level of blood pressure is determined by five factors: cardiac output, peripheral vascular resistance, volume of circulating blood, viscosity, and elasticity of the vessel walls.
3. A patients weekly blood pressure readings for 2 months have ranged between 124/84 mm Hg and 136/88 mm Hg, with an average reading of 126/86 mm Hg. The nurse knows that this blood pressure falls within which blood pressure category? 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.
Prehypertension- prehypertension blood pressure readings are systolic readings of 120 to 139 mm Hg or diastolic readings of 50 to 89 mm Hg.
6. 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
Presence of kyphosis (hunch back) and flexion in the knees and hips
15. 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. On the basis of this observation, the nurse should: 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.
Recognize that a tripod position is often used when a patient is having respiratory difficulties.
37. 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; then 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 allow the infant to become more familiar with her and then measure the infants vital signs.
Respirations are measured; then pulse and temperature.
24. 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 childs respirations?
Respirations should be counted for 1 full minute, noticing rate and rhythm.
43. 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?
Systolic blood pressure may be falsely low. If an auscultatory gap is undetected, then a falsely low systolic or falsely high diastolic reading may result, which is common in patients with hypertension.
27. A nurse is helping at a health fair at a 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 taken in men. b. The blood pressure of a Black adult is usually higher than that of a White adult 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 teenagers blood pressure reading will be lower than that of an adult.
The blood pressure of a Black adult is usually higher than that of a White adult of the same age.
13. When evaluating the temperature of older adults, the nurse should remember which aspect about an older adults body temperature? a. The body temperature of the older adult is lower than that of a younger adult. b. An older adults 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.
The body temperature of the older adult is lower than that of a younger adult.
42. 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 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 sounds can be used for the diastolic reading in children.
The disappearance of phase V Korotkoff sounds can be used for the diastolic reading in children. (as well as adults)
38. A 4-month-old child is at the clinic for a well-baby check-up and immunizations. Which of these actions is most appropriate when the nurse is assessing an infants vital signs? a. The infants radial pulse should be palpated, and the nurse should notice 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 infants blood pressure should be assessed by using a stethoscope with a large diaphragm piece to hear the soft muffled Korotkoff sounds. d. The infants chest should be observed and the respiratory rate counted for 1 minute; the respiratory pattern may vary significantly.
The nurse should auscultate an apical rate for 1 minute and then assess for any normal irregularities, such as sinus arrhythmia
20. When assessing a patients pulse, the nurse should also notice which of these characteristics? a. Force b. Pallor c. Capillary refill time d. Timing in the cardiac cycle
The pulse is assessed for rate, rhythm, and force.
17. The nurse is taking temperatures in a clinic with a TMT. Which statement is true regarding use of the TMT? a. A tympanic temperature is more time consuming than a rectal temperature. b. The tympanic method is more invasive and uncomfortable than the oral method. c. The risk of cross-contamination is reduced, compared with the rectal route. d. The tympanic membrane most accurately reflects the temperature in the ophthalmic artery.
The risk of cross-contamination is reduced, compared with the rectal route.
25. A patients blood pressure is 118/82 mm Hg. He asks the nurse, What do the numbers mean? The nurses best reply is: a. The numbers are within the normal range and are 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.
The top number is the systolic blood pressure and reflects the pressure of the blood against the arteries when the heart contracts
49. 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.
The width of the rubber bladder should equal 40% of the circumference of the persons arm. The length of the bladder should equal 80% of this circumference.
8. 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 infants 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
To measure the chest circumference, the tape is encircled around the chest at the nipple line. The length should be measured on a horizontal measuring board. Weight should be measured on a platform-type balance scale. Head circumference is measured with the tape around the head, aligned at the eyebrows, and at the prominent frontal and occipital bonesthe widest span is correct.
14. 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. 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.
Unexplained weight loss often accompanies short-term illnesses.
18. To assess a rectal temperature accurately in an adult, the nurse would: a. Use a lubricated blunt tip 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.
Use a lubricated blunt tip thermometer.
48. The nurse is counting an infants respirations. Which technique is correct? a.Watching the chest rise and fall b.Watching the abdomen for movement c.Placing a hand across the infants chest d.Using a stethoscope to listen to the breath sounds
Watching the abdomen for movement is the correct technique because the infants respirations are normally more diaphragmatic than thoracic.
During an initial home visit, the patient's temperature is noted to be 97.4F. How would you interpret this? A) It cannot be evaluated without knowledge of the person's age. B) It is below normal. The person should be assessed for possible hypothermia. C) It should be retaken by the rectal route, because this best reflects core body temperature. D) It should be reevaluated at the next visit before a decision is made. A.
a
Pulse pressure is described as: A) The difference between the systolic and diastolic pressure. B) A reflection of the viscosity of the blood. C) Another way to express the systolic pressure. D) A measure of vasoconstriction.
a
the nurse is conducting a health fair for older adults, which statement is true regarding vital sign measurements in aging adults?
an increased respiratory rate and a shallower inspiratory phase are possible findings
After assessing the patient's pulse, the practitioner determines it to be "normal." This would be recorded as: A) 3+ B) 2+ C) 1+ D) 0
b
The general survey consists of four distinct areas. These areas include: A) mental status, speech, behavior, and mood and affect. B) gait, range of motion, mental status, and behavior. C) physical appearance, body structure, mobility, and behavior. D) level of consciousness, personal hygiene, mental status, and physical condition.
c
Which changes regarding height and weight occur during the 80s and 90s? A) Both increase. B) Weight increases, and height decreases. C) Both decrease. D) Both remain the same as during the 70s.
c
12. When measuring a patients body temperature, the nurse keeps in mind that body temperature is influenced by: a. Constipation. b. Patients emotional state. c. Diurnal cycle. d. Nocturnal cycle.
diurnal cycle
congenital form of aorta narrowing:
coarctation
7. 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
comatose adult
Force of pulse @ 3+
full, bounding
4. During an examination of a child, the nurse considers that physical growth is the best index of a childs: a. General health. b. Genetic makeup. c. Nutritional status. d. Activity and exercise patterns.
general health
46. Which of these specific measurements is the best index of a childs general health?
height and weight
23. The nurse is assessing the vital signs of a 20-year-old male marathon runner and documents the following vital signs: temperature36 C; pulse48 beats per minute; respirations14 breaths per minute; blood pressure104/68 mm Hg. Which statement is true concerning these results?
normal
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, the nurse would: 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.
normal- The newborns head measures approximately 32 to 38 cm and is approximately 2 cm larger than the chest circumference. Between 6 months and 2 years, both measurements are approximately the same, and after age 2 years, the chest circumference is greater than the head circumference.
The force of blood flares arterial walls and generates a pressure wave which is known as a:
pulse
32. The nurse has collected the following information on a patient: palpated blood pressure180 mm Hg; auscultated blood pressure170/100 mm Hg; apical pulse60 beats per minute; radial pulse70 beats per minute. What is the patients pulse pressure? a. 10 b. 70 c. 80 d. 100
pulse pressure pulse pressure is difference between systolic and diastolic blood pressure (170 100 = 70) and reflects the stroke volume.
11. The nurse is examining a patient who is complaining of feeling cold. Which is a mechanism of heat loss in the body? a. Exercise b. Radiation c. Metabolism d. Food digestion
radiation
9. The nurse knows that one advantage of the tympanic membrane thermometer (TMT) is that: a. Rapid measurement is useful for uncooperative younger children. b. Using the TMT is the most accurate method for measuring body temperature in newborn infants. c. Measuring temperature using the TMT is inexpensive. d. Studies strongly support the use of the TMT in children under the age 6 years.
rapid measurement is useful in uncooperative younger children
heart rate varies w/ the respiratory cycle. Speeding up at the peak of inspiration and slowing to normal during expiration:
sinus arrythmia
