Chapters 8-11 health assessment

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?

ANS: 62 The pulse pressure is the difference between the systolic and diastolic and reflects the stroke volume. The pulse rate is not necessary for pulse pressure calculations. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 137

29. 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 his blood pressure in the supine position, which will provide a more accurate reading and will allow him to relax at the same time.

ANS: A A comfortable, relaxed person yields a valid blood pressure. Many people are anxious at the beginning of an examination; the nurse should allow at least a 5-minute rest period before measuring blood pressure. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 139

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.

ANS: A A lubricated rectal thermometer (with a short, blunt tip) is inserted only 2 to 3 cm (1 inch) into the adult rectum and left in place for 2 minutes. Cigarette smoking does not alter rectal temperatures. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 133

21. A man is at the clinic for a physical examination. He states that he is very anxious about the physical examination. What steps can the nurse take to make him more comfortable? a. Appear unhurried and confident when examining him. b. Stay in the room when he undresses in case he needs assistance. c. Ask him to change into an examining gown and to take off his undergarments. d. Defer measuring vital signs until the end of the examination, which allows him time to become comfortable.

ANS: A Anxiety can be reduced by an examiner who is confident, self-assured, considerate, and unhurried. Familiar and relatively nonthreatening actions, such as measuring the persons vital signs, will gradually accustom the person to the examination. DIF: Cognitive Level: Applying (Application) REF: p. 121

8. The nurse is reviewing percussion techniques with a newly graduated nurse. Which technique, if used by the new nurse, indicates that more review is needed? a. Percussing once over each area b. Quickly lifting the striking finger after each stroke c. Striking with the fingertip, not the finger pad d. Using the wrist to make the strikes, not the arm

ANS: A For percussion, the nurse should percuss two times over each location. The striking finger should be quickly lifted because a resting finger damps off vibrations. The tip of the striking finger should make contact, not the pad of the finger. The wrist must be relaxed and is used to make the strikes, not the arm. DIF: Cognitive Level: Applying (Application) REF: p. 116

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? a. Hypopituitary dwarfism b. Achondroplastic dwarfism c. Marfan syndrome d. Acromegaly

ANS: A 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. The childs appearance fits this description. Achondroplastic dwarfism is a genetic disorder resulting in characteristic deformities; Marfan syndrome is an inherited connective tissue disorder characterized by a tall, thin stature and other features. Acromegaly is the result of excessive secretion of growth hormone in adulthood. (For more information, see Table 9-5, Abnormalities in Body Height and Proportion.) DIF: Cognitive Level: Applying (Application) REF: p. 156

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? a. 200/92 b. 200/100 c. 100/200/92 d. 200/100/92

ANS: A 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). DIF: Cognitive Level: Analyzing (Analysis) REF: p. 141

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.

ANS: A In older adults, the body temperature is usually lower than in other age groups, with a mean temperature of 36.2 C. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 133

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.

ANS: A Orthostatic vital signs should be taken when the person is hypertensive or is taking antihypertensive medications, when the person reports fainting or syncope, or when volume depletion is suspected. The blood pressure and pulse readings are recorded in the supine, sitting, and standing positions. DIF: Cognitive Level: Applying (Application) REF: pp. 142-143

16. The nurse will use which technique of assessment to determine the presence of crepitus, swelling, and pulsations? a. Palpation b. Inspection c. Percussion d. Auscultation

ANS: A Palpation applies the sense of touch to assess texture, temperature, moisture, organ location and size, as well as any swelling, vibration or pulsation, rigidity or spasticity, crepitation, presence of lumps or masses, and the presence of tenderness or pain. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 115

4. Which of these techniques uses the sense of touch to assess texture, temperature, moisture, and swelling when the nurse is assessing a patient? a. Palpation b. Inspection c. Percussion d. Auscultation

ANS: A Palpation uses the sense of touch to assess the patient for these factors. Inspection involves vision; percussion assesses through the use of palpable vibrations and audible sounds; and auscultation uses the sense of hearing. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 115

9. When percussing over the liver of a patient, the nurse notices a dull sound. The nurse should: a. Consider this a normal finding. b. Palpate this area for an underlying mass. c. Reposition the hands, and attempt to percuss in this area again. d. Consider this finding as abnormal, and refer the patient for additional treatment.

ANS: A Percussion over relatively dense organs, such as the liver or spleen, will produce a dull sound. The other responses are not correct. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 117

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.

ANS: A Physical growth is the best index of a childs general health; recording the childs height and weight helps determine normal growth patterns. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 146

19. Which technique is correct when the nurse is assessing the radial pulse of a patient? The pulse is counted for: a. 1 minute, if the rhythm is irregular. b. 15 seconds and then multiplied by 4, if the rhythm is regular. c. 2 full minutes to detect any variation in amplitude. d. 10 seconds and then multiplied by 6, if the patient has no history of cardiac abnormalities.

ANS: A Recent research suggests that the 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. DIF: Cognitive Level: Applying (Application) REF: p. 134

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? a. Respirations should be counted for 1 full minute, noticing rate and rhythm. b. Childs pulse and respirations should be simultaneously checked for 30 seconds. c. Childs respirations should be checked for a minimum of 5 minutes to identify any variations in his or her respiratory pattern. d. Patients respirations should be counted for 15 seconds and then multiplied by 4 to obtain the number of respirations per minute.

ANS: A Respirations are counted for 1 full minute if an abnormality is suspected. The other responses are not correct actions. DIF: Cognitive Level: Applying (Application) REF: p. 136

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.

ANS: A The TMT is useful for young children who may not cooperate for oral temperatures and fear rectal temperatures. However, the use a TMT with newborn infants and young children is conflicting. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 147

14. The nurse is preparing to use a stethoscope for auscultation. Which statement is true regarding the diaphragm of the stethoscope? The diaphragm: a. Is used to listen for high-pitched sounds. b. Is used to listen for low-pitched sounds. c. Should be lightly held against the persons skin to block out low-pitched sounds. d. Should be lightly held against the persons skin to listen for extra heart sounds and murmurs.

ANS: A The diaphragm of the stethoscope is best for listening to high-pitched sounds such as breath, bowel, and normal heart sounds. It should be firmly held against the persons skin, firmly enough to leave a ring. The bell of the stethoscope is best for soft, low-pitched sounds such as extra heart sounds or murmurs. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 117

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

ANS: A The general survey is a study of the whole person that includes observing the patients physical appearance, body structure, mobility, and behavior. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 127

27. When preparing to perform a physical examination on an infant, the nurse should: a. Have the parent remove all clothing except the diaper on a boy. b. Instruct the parent to feed the infant immediately before the examination. c. Encourage the infant to suck on a pacifier during the abdominal examination. d. Ask the parent to leave the room briefly when assessing the infants vital signs.

ANS: A The parent should always be present to increase the childs feeling of security and to understand normal growth and development. The timing of the examination should be 1 to 2 hours after feeding when the baby is neither too drowsy nor too hungry. Infants do not object to being nude; clothing should be removed, but a diaper should be left on a boy. DIF: Cognitive Level: Applying (Application) REF: p. 122

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

ANS: A The pulse is assessed for rate, rhythm, and force. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 134

6. The nurse would use bimanual palpation technique in which situation? a. Palpating the thorax of an infant b. Palpating the kidneys and uterus c. Assessing pulsations and vibrations d. Assessing the presence of tenderness and pain

ANS: B Bimanual palpation requires the use of both hands to envelop or capture certain body parts or organs such as the kidneys, uterus, or adnexa. The other situations are not appropriate for bimanual palpation. DIF: Cognitive Level: Applying (Application) REF: p. 115

28. A 6-month-old infant has been brought to the well-child clinic for a check-up. She is currently sleeping. What should the nurse do first when beginning the examination? a. Auscultate the lungs and heart while the infant is still sleeping. b. Examine the infants hips, because this procedure is uncomfortable. c. Begin with the assessment of the eye, and continue with the remainder of the examination in a head-to-toe approach. d. Wake the infant before beginning any portion of the examination to obtain the most accurate assessment of body systems.

ANS: A When the infant is quiet or sleeping is an ideal time to assess the cardiac, respiratory, and abdominal systems. Assessment of the eye, ear, nose, and throat are invasive procedures that should be performed at the end of the examination. DIF: Cognitive Level: Applying (Application) REF: p. 123

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.

ANS: A With an infant, the order of vital sign measurements is reversed to respiration, pulse, and temperature. Taking the temperature first, especially if it is rectal, may cause the infant to cry, which will increase the respiratory and pulse rate, thus masking the normal resting values. The vital signs are measured with the same purpose and frequency as would be measured in an adult. DIF: Cognitive Level: Applying (Application) REF: p. 147

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. 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 above 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.

ANS: A, B, D, E Several factors can result in blood pressure readings that are too high or too low. Having the patients arm held above the level of the heart is one part of the correct technique. (Refer to Table 9-5, Common Errors in Blood Pressure Measurement.) DIF: Cognitive Level: Applying (Application) REF: p. 142

26. The nurse is examining an infant and prepares to elicit the Moro reflex at which time during the examination? a. When the infant is sleeping b. At the end of the examination c. Before auscultation of the thorax d. Halfway through the examination

ANS: B The Moro or startle reflex is elicited at the end of the examination because it may cause the infant to cry. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 123

1. The nurse is preparing to palpate the thorax and abdomen of a patient. Which of these statements describes the correct technique for this procedure? Select all that apply. a. Warm the hands first before touching the patient. b. For deep palpation, use one long continuous palpation when assessing the liver. c. Start with light palpation to detect surface characteristics. d. Use the fingertips to examine skin texture, swelling, pulsation, and presence of lumps. e. Identify any tender areas, and palpate them last. f. Use the palms of the hands to assess temperature of the skin.

ANS: A, C, D, E The hands should always be warmed before beginning palpation. Intermittent pressure rather than one long continuous palpation is used; any tender areas are identified and palpated last. Fingertips are used to examine skin texture, swelling, pulsation, and the presence of lumps. The dorsa (backs) of the hands are used to assess skin temperature because the skin on the dorsa is thinner than on the palms. DIF: Cognitive Level: Applying (Application) REF: p. 115

2. The nurse is preparing to perform a physical assessment. Which statement is true about the physical assessment? The inspection phase: a. Usually yields little information. b. Takes time and reveals a surprising amount of information. c. May be somewhat uncomfortable for the expert practitioner. d. Requires a quick glance at the patients body systems before proceeding with palpation.

ANS: B A focused inspection takes time and yields a surprising amount of information. Initially, the examiner may feel uncomfortable, staring at the person without also doing something. A focused assessment is significantly more than a quick glance. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 115

40. During an examination of a patients abdomen, the nurse notes that the abdomen is rounded and firm to the touch. During percussion, the nurse notes a drumlike quality of the sounds across the quadrants. This type of sound indicates: a. Constipation. b. Air-filled areas. c. Presence of a tumor. d. Presence of dense organs.

ANS: B A musical or drumlike sound (tympany) is heard when percussion occurs over an air-filled viscus, such as the stomach or intestines. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 117

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. Normal blood pressure b. Prehypertension c. Stage 1 hypertension d. Stage 2 hypertension

ANS: B According to the Seventh Report of the Joint National Committee (JNC 7) guidelines, prehypertension blood pressure readings are systolic readings of 120 to 139 mm Hg or diastolic readings of 50 to 89 mm Hg. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 159

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.

ANS: B Aging causes a decrease in vital capacity and decreased inspiratory reserve volume. The examiner may notice a shallower inspiratory phase and an increased respiratory rate. An increase in the rigidity of the arterial walls makes the pulse actually easier to palpate. Pulse pressure is widened in older adults, and changes in the body temperature regulatory mechanism leave the older person less likely to have fever but at a greater risk for hypothermia. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 151

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.

ANS: B In the United States, a Black adults blood pressure is usually higher than that of a White adult of the same age. The incidence of hypertension is twice as high in Blacks as it is in Whites. After menopause, blood pressure in women is higher than in men; blood pressure measurements in people who are obese are usually higher than in those who are not overweight. Normally, a gradual rise occurs through childhood and into the adult years. DIF: Cognitive Level: Applying (Application) REF: p. 137

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? a. The patient is experiencing tachycardia. b. These are normal vital signs for a healthy, athletic adult. c. The patients pulse rate is not normalhis physician should be notified. d. On the basis of these readings, the patient should return to the clinic in 1 week.

ANS: B In the adult, a heart rate less than 50 beats per minute is called bradycardia, which normally occurs in the well-trained athlete whose heart muscle develops along with the skeletal muscles. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 135

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.

ANS: B 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. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 139

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? a. These readings are a normal response and attributable to changes in the patients 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 patients age.

ANS: B Orthostatic hypotension is 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. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 143

12. A patient has suddenly developed shortness of breath and appears to be in significant respiratory distress. After calling the physician and placing the patient on oxygen, which of these actions is the best for the nurse to take when further assessing the patient? a. Count the patients respirations. b. Bilaterally percuss the thorax, noting any differences in percussion tones. c. Call for a chest x-ray study, and wait for the results before beginning an assessment. d. Inspect the thorax for any new masses and bleeding associated with respirations.

ANS: B Percussion is always available, portable, and offers instant feedback regarding changes in underlying tissue density, which may yield clues of the patients physical status. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 115

46. Which of these specific measurements is the best index of a childs general health? a. Vital signs b. Height and weight c. Head circumference d. Chest circumference

ANS: B Physical growth, measured by height and weight, is the best index of a childs general health. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 146

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

ANS: B Pulse pressure is the difference between systolic and diastolic blood pressure (170 100 = 70) and reflects the stroke volume. DIF: Cognitive Level: Applying (Application) REF: p. 137

25. The nurse keeps in mind that the most important reason to share information and to offer brief teaching while performing the physical examination is to help the: a. Examiner feel more comfortable and to gain control of the situation. b. Examiner to build rapport and to increase the patients confidence in him or her. c. Patient understand his or her disease process and treatment modalities. d. Patient identify questions about his or her disease and the potential areas of patient education.

ANS: B Sharing information builds rapport and increases the patients confidence in the examiner. It also gives the patient a little more control in a situation during which feeling completely helpless is often present. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 122

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.

ANS: B 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. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 135

39. While auscultating heart sounds, the nurse hears a murmur. Which of these instruments should be used to assess this murmur? a. Electrocardiogram b. Bell of the stethoscope c. Diaphragm of the stethoscope d. Palpation with the nurses palm of the hand

ANS: B The bell of the stethoscope is best for soft, low-pitched sounds such as extra heart sounds or murmurs. The diaphragm of the stethoscope is best used for high-pitched sounds such as breath, bowel, and normal heart sounds. DIF: Cognitive Level: Applying (Application) REF: p. 117

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

ANS: B The body maintains a steady temperature through a thermostat or feedback mechanism, which is regulated in the hypothalamus of the brain. The hypothalamus regulates heat production from metabolism, exercise, food digestion, and external factors with heat loss through radiation, evaporation of sweat, convection, and conduction. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 132

3. The nurse is assessing a patients skin during an office visit. What part of the hand and technique should be used to best assess the patients skin temperature? a. Fingertips; they are more sensitive to small changes in temperature. b. Dorsal surface of the hand; the skin is thinner on this surface than on the palms. c. Ulnar portion of the hand; increased blood supply in this area enhances temperature sensitivity. d. Palmar surface of the hand; this surface is the most sensitive to temperature variations because of its increased nerve supply in this area.

ANS: B The dorsa (backs) of the hands and fingers are best for determining temperature because the skin is thinner on the dorsal surfaces than on the palms. Fingertips are best for fine, tactile discrimination. The other responses are not useful for palpation. DIF: Cognitive Level: Applying (Application) REF: p. 115

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.

ANS: B The nurse palpates or auscultates an apical rate with infants and toddlers. The pulse should be counted for 1 full minute to account for normal irregularities, such as sinus arrhythmia. Children younger than 3 years of age have such small arm vessels; consequently, hearing Korotkoff sounds with a stethoscope is difficult. The nurse should use either an electronic blood pressure device that uses oscillometry or a Doppler ultrasound device to amplify the sounds. DIF: Cognitive Level: Applying (Application) REF: p. 148

22. When performing a physical examination, safety must be considered to protect the examiner and the patient against the spread of infection. Which of these statements describes the most appropriate action the nurse should take when performing a physical examination? a. Washing ones hands after removing gloves is not necessary, as long as the gloves are still intact. b. Hands are washed before and after every physical patient encounter. c. Hands are washed before the examination of each body system to prevent the spread of bacteria from one part of the body to another. d. Gloves are worn throughout the entire examination to demonstrate to the patient concern regarding the spread of infectious diseases.

ANS: B The nurse should wash his or her hands before and after every physical patient encounter; after contact with blood, body fluids, secretions, and excretions; after contact with any equipment contaminated with body fluids; and after removing gloves. Hands should be washed after gloves have been removed, even if the gloves appear to be intact. Gloves should be worn when potential contact with any body fluids is present. DIF: Cognitive Level: Applying (Application) REF: p. 120

1. When performing a physical assessment, the first technique the nurse will always use is: a. Palpation. b. Inspection. c. Percussion. d. Auscultation.

ANS: B The skills requisite for the physical examination are inspection, palpation, percussion, and auscultation. The skills are performed one at a time and in this order (with the exception of the abdominal assessment, during which auscultation takes place before palpation and percussion). The assessment of each body system begins with inspection. A focused inspection takes time and yields a surprising amount of information. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 115

13. The nurse is teaching a class on basic assessment skills. Which of these statements is true regarding the stethoscope and its use? a. Slope of the earpieces should point posteriorly (toward the occiput). b. Although the stethoscope does not magnify sound, it does block out extraneous room noise. c. Fit and quality of the stethoscope are not as important as its ability to magnify sound. d. Ideal tubing length should be 22 inches to dampen the distortion of sound.

ANS: B The stethoscope does not magnify sound, but it does block out extraneous room sounds. The slope of the earpieces should point forward toward the examiners nose. Long tubing will distort sound. The fit and quality of the stethoscope are both important. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 116

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.

ANS: B The thermometer should be left in place 3 to 4 minutes if the person is afebrile and up to 8 minutes if the person is febrile. The nurse should wait 15 minutes if the person has just ingested hot or iced liquids and 2 minutes if he or she has just smoked. DIF: Cognitive Level: Applying (Application) REF: p. 133

28. The nurse notices 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.

ANS: B Using a cuff that is too narrow yields a falsely high blood pressure because it takes extra pressure to compress the artery. DIF: Cognitive Level: Applying (Application) REF: p. 139

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

ANS: B Watching the abdomen for movement is the correct technique because the infants respirations are normally more diaphragmatic than thoracic. The other responses do not reflect correct techniques. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 149

31. With which of these patients would it be most appropriate for the nurse to use games during the assessment, such as having the patient blow out the light on the penlight? a. Infant b. Preschool child c. School-age child d. Adolescent

ANS: B When assessing preschool children, using games or allowing them to play with the equipment to reduce their fears can be helpful. Such games are not appropriate for the other age groups. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 124

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

ANS: B 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. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 151

32. The nurse is preparing to examine a 4-year-old child. Which action is appropriate for this age group? a. Explain the procedures in detail to alleviate the childs anxiety. b. Give the child feedback and reassurance during the examination. c. Do not ask the child to remove his or her clothes because children at this age are usually very private. d. Perform an examination of the ear, nose, and throat first, and then examine the thorax and abdomen.

ANS: B With preschool children, short, simple explanations should be used. Children at this age are usually willing to undress. An examination of the head should be performed last. During the examination, needed feedback and reassurance should be given to the preschooler. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 124

41. The nurse is preparing to examine a 6-year-old child. Which action is most appropriate? a. The thorax, abdomen, and genitalia are examined before the head. b. Talking about the equipment being used is avoided because doing so may increase the childs anxiety. c. The nurse should keep in mind that a child at this age will have a sense of modesty. d. The child is asked to undress from the waist up.

ANS: C A 6-year-old child has a sense of modesty. The child should undress him or herself, leaving underpants on and using a gown or drape. A school-age child is curious to know how equipment works, and the sequence should progress from the childs head to the toes. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 124

1. When evaluating a patients pain, the nurse knows that an example of acute pain would be: a. Arthritic pain. b. Fibromyalgia. c. Kidney stones. d. Low back pain.

ANS: C Acute pain is short-term and dissipates after an injury heals, such as with kidney stones. The other conditions are examples of chronic pain during which the pain continues for 6 months or longer and does not stop when the injury heals. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 164

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.

ANS: C An auscultatory gap occurs in approximately 5% of the people, most often in those with hypertension. 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. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 139

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.

ANS: C An unexplained weight loss may be a sign of a short-term illness or a chronic illness such as endocrine disease, malignancy, depression, anorexia nervosa, or bulimia. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 129

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

ANS: C Changes that occur in the aging person include more prominent bony landmarks, decreased body weight (especially in men), a decrease in subcutaneous fat from the face and periphery, and additional fat deposited on the abdomen and hips. Postural changes of kyphosis and slight flexion in the knees and hips also occur. DIF: Cognitive Level: Applying (Application) REF: p. 150

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? a. Marfan syndrome b. Gigantism c. Cushing syndrome d. Acromegaly

ANS: C Cushing syndrome is characterized by weight gain and edema with central trunk and cervical obesity (buffalo hump) and round plethoric face (moon face). Excessive catabolism causes muscle wasting; weakness; thin arms and legs; reduced height; and thin, fragile skin with purple abdominal striae, bruising, and acne. (See Table 9-5, Abnormalities in Body Height and Proportion, for the definitions of the other conditions.) DIF: Cognitive Level: Applying (Application) REF: p. 157

19. The nurse is unable to palpate the right radial pulse on a patient. The best action would be to: a. Auscultate over the area with a fetoscope. b. Use a goniometer to measure the pulsations. c. Use a Doppler device to check for pulsations over the area. d. Check for the presence of pulsations with a stethoscope.

ANS: C Doppler devices are used to augment pulse or blood pressure measurements. Goniometers measure joint range of motion. A fetoscope is used to auscultate fetal heart tones. Stethoscopes are used to auscultate breath, bowel, and heart sounds. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 120

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

ANS: C Excessive secretions of growth hormone in adulthood after normal completion of body growth causes an overgrowth of the bones in the face, head, hands, and feet but no change in height. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 156

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? 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.

ANS: C 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. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 140

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.

ANS: C If the person is known to have hypertension, is taking antihypertensive medications, or reports a history of fainting or syncope, then the blood pressure reading should be taken in three positions: lying, sitting, and standing. DIF: Cognitive Level: Applying (Application) REF: pp. 142-143

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.

ANS: C MAP is the pressure that forces blood into the tissues, averaged over the cardiac cycle. Stroke volume is reflected by the blood pressure. MAP is not an arithmetic average of systolic and diastolic pressures because diastole lasts longer; rather, it is a value closer to diastolic pressure plus one third of the pulse pressure. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 137

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.

ANS: C Normal temperature is influenced by the diurnal cycle, exercise, and age. The other responses do not influence body temperature. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 133

2. Which statement indicates that the nurse understands the pain experienced by an older adult? a. Older adults must learn to tolerate pain. b. Pain is a normal process of aging and is to be expected. c. Pain indicates a pathologic condition or an injury and is not a normal process of aging. d. Older individuals perceive pain to a lesser degree than do younger individuals.

ANS: C Pain indicates a pathologic condition or an injury and should never be considered something that an older adult should expect or tolerate. Pain is not a normal process of aging, and no evidence suggests that pain perception is reduced with aging. DIF: Cognitive Level: Applying (Application) REF: p. 165

7. The nurse is preparing to percuss the abdomen of a patient. The purpose of the percussion is to assess the __________ of the underlying tissue. a. Turgor b. Texture c. Density d. Consistency

ANS: C Percussion yields a sound that depicts the location, size, and density of the underlying organ. Turgor and texture are assessed with palpation. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 115

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

ANS: C Rectal temperatures should be taken when the other routes are impractical, such as for comatose or confused persons, for those in shock, or for those who cannot close the mouth because of breathing or oxygen tubes, a wired mandible, or other facial dysfunctions. DIF: Cognitive Level: Applying (Application) REF: p. 133

4. A patient states that the pain medication is not working and rates his postoperative pain at a 10 on a 1-to-10 scale. Which of these assessment findings indicates an acute pain response to poorly controlled pain? a. Confusion b. Hyperventilation c. Increased blood pressure and pulse d. Depression

ANS: C Responses to poorly controlled acute pain include tachycardia, elevated blood pressure, and hypoventilation. Confusion and depression are associated with poorly controlled chronic pain (see Table 10-1). DIF: Cognitive Level: Analyzing (Analysis) REF: p. 172

36. Which of these statements is true regarding the use of Standard Precautions in the health care setting? a. Standard Precautions apply to all body fluids, including sweat. b. Use alcohol-based hand rub if hands are visibly dirty. c. Standard Precautions are intended for use with all patients, regardless of their risk or presumed infection status. d. Standard Precautions are to be used only when nonintact skin, excretions containing visible blood, or expected contact with mucous membranes is present.

ANS: C Standard Precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources and are intended for use for all patients, regardless of their risk or presumed infection status. Standard Precautions apply to blood and all other body fluids, secretions and excretions except sweatregardless of whether they contain visible blood, nonintact skin, or mucous membranes. Hands should be washed with soap and water if visibly soiled with blood or body fluids. Alcohol-based hand rubs can be used if hands are not visibly soiled. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 120

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.

ANS: C The TMT is a noninvasive, nontraumatic device that is extremely quick and efficient. The chance of cross-contamination with the TMT is minimal because the ear canal is lined with skin, not mucous membranes. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 134

29. A 2-year-old child has been brought to the clinic for a well-child checkup. The best way for the nurse to begin the assessment is to: a. Ask the parent to place the child on the examining table. b. Have the parent remove all of the childs clothing before the examination. c. Allow the child to keep a security object such as a toy or blanket during the examination. d. Initially focus the interactions on the child, essentially ignoring the parent until the childs trust has been obtained.

ANS: C The best place to examine the toddler is on the parents lap. Toddlers understand symbols; therefore, a security object is helpful. Initially, the focus is more on the parent, which allows the child to adjust gradually and to become familiar with you. A 2-year-old child does not like to take off his or her clothes. Therefore, ask the parent to undress one body part at a time. DIF: Cognitive Level: Applying (Application) REF: p. 123

23. The nurse is examining a patients lower leg and notices a draining ulceration. Which of these actions is most appropriate in this situation? a. Washing hands, and contacting the physician b. Continuing to examine the ulceration, and then washing hands c. Washing hands, putting on gloves, and continuing with the examination of the ulceration d. Washing hands, proceeding with rest of the physical examination, and then continuing with the examination of the leg ulceration

ANS: C The examiner should wear gloves when the potential contact with any body fluids is present. In this situation, the nurse should wash his or her hands, put on gloves, and continue examining the ulceration. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 120

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.

ANS: C 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. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 134

35. The most important step that the nurse can take to prevent the transmission of microorganisms in the hospital setting is to: a. Wear protective eye wear at all times. b. Wear gloves during any and all contact with patients. c. Wash hands before and after contact with each patient. d. Clean the stethoscope with an alcohol swab between patients.

ANS: C The most important step to decrease the risk of microorganism transmission is to wash hands promptly and thoroughly before and after physical contact with each patient. Stethoscopes should also be cleansed with an alcohol swab before and after each patient contact. The best routine is to combine stethoscope rubbing with hand hygiene each time hand hygiene is performed. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 120

24. During the examination, offering some brief teaching about the patients body or the examiners findings is often appropriate. Which one of these statements by the nurse is most appropriate? a. Your atrial dysrhythmias are under control. b. You have pitting edema and mild varicosities. c. Your pulse is 80 beats per minute, which is within the normal range. d. Im using my stethoscope to listen for any crackles, wheezes, or rubs.

ANS: C The sharing of some information builds rapport, as long as the patient is able to understand the terminology. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 122

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.

ANS: C The systolic pressure is the maximum pressure felt on the artery during left ventricular contraction, or systole. The diastolic pressure is the elastic recoil, or resting, pressure that the blood constantly exerts in between each contraction. The nurse should answer the patients question and use terms he can understand. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 136

10. The nurse is unable to identify any changes in sound when percussing over the abdomen of an obese patient. What should the nurse do next? a. Ask the patient to take deep breaths to relax the abdominal musculature. b. Consider this finding as normal, and proceed with the abdominal assessment. c. Increase the amount of strength used when attempting to percuss over the abdomen. d. Decrease the amount of strength used when attempting to percuss over the abdomen.

ANS: C The thickness of the persons body wall will be a factor. The nurse needs a stronger percussion stroke for persons with obese or very muscular body walls. The force of the blow determines the loudness of the note. The other actions are not correct. DIF: Cognitive Level: Applying (Application) REF: p. 116

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

ANS: C 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. DIF: Cognitive Level: Applying (Application) REF: p. 147

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.

ANS: C When blood pressure measured at the arm is excessively high, particularly in adolescents and young adults, it is compared with thigh pressure to check for coarctation of the aorta. The popliteal artery is auscultated for the reading. 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. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 143

42. During auscultation of a patients heart sounds, the nurse hears an unfamiliar sound. The nurse should: a. Document the findings in the patients record. b. Wait 10 minutes, and auscultate the sound again. c. Ask the patient how he or she is feeling. d. Ask another nurse to double check the finding.

ANS: D If an abnormal finding is not familiar, then the nurse may ask another examiner to double check the finding. The other responses do not help identify the unfamiliar sound. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 122

5. A 60-year-old woman has developed reflexive sympathetic dystrophy after arthroscopic repair of her shoulder. A key feature of this condition is that the: a. Affected extremity will eventually regain its function. b. Pain is felt at one site but originates from another location. c. Patients pain will be associated with nausea, pallor, and diaphoresis. d. Slightest touch, such as a sleeve brushing against her arm, causes severe and intense pain.

ANS: D A key feature of reflexive sympathetic dystrophy is that a typically innocuous stimulus can create a severe, intensely painful response. The affected extremity becomes less functional over time. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 178

2. When measuring a patients weight, the nurse is aware of which of these guidelines? 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.

ANS: D A standardized balance scale is used to measure weight. The patient should remove his or her shoes and heavy outer clothing. If a sequence of repeated weights is necessary, then the nurse should attempt to weigh the patient at approximately the same time of day and with the same types of clothing worn each time. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 129

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.

ANS: D Assuming a tripod positionleaning forward with arms braced on chair armsoccurs with chronic pulmonary disease. The other actions or assumptions are not correct. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 128

37. The nurse is preparing to assess a hospitalized patient who is experiencing significant shortness of breath. How should the nurse proceed with the assessment? a. The patient should lie down to obtain an accurate cardiac, respiratory, and abdominal assessment. b. A thorough history and physical assessment information should be obtained from the patients family member. c. A complete history and physical assessment should be immediately performed to obtain baseline information. d. Body areas appropriate to the problem should be examined and then the assessment completed after the problem has resolved.

ANS: D Both altering the position of the patient during the examination and collecting a mini database by examining the body areas appropriate to the problem may be necessary in this situation. An assessment may be completed later after the distress is resolved. DIF: Cognitive Level: Applying (Application) REF: p. 126

30. The nurse is examining a 2-year-old child and asks, May I listen to your heart now? Which critique of the nurses technique is most accurate? a. Asking questions enhances the childs autonomy b. Asking the child for permission helps develop a sense of trust c. This question is an appropriate statement because children at this age like to have choices d. Children at this age like to say, No. The examiner should not offer a choice when no choice is available

ANS: D Children at this age like to say, No. Choices should not be offered when no choice is really available. If the child says, No and the nurse does it anyway, then the nurse loses trust. Autonomy is enhanced by offering a limited option, Shall I listen to your heart next or your tummy? DIF: Cognitive Level: Analyzing (Analysis) REF: p. 123

33. When examining a 16-year-old male teenager, the nurse should: a. Discuss health teaching with the parent because the teen is unlikely to be interested in promoting wellness. b. Ask his parent to stay in the room during the history and physical examination to answer any questions and to alleviate his anxiety. c. Talk to him the same manner as one would talk to a younger child because a teens level of understanding may not match his or her speech. d. Provide feedback that his body is developing normally, and discuss the wide variation among teenagers on the rate of growth and development.

ANS: D During the examination, the adolescent needs feedback that his or her body is healthy and developing normally. The adolescent has a keen awareness of body image and often compares him or herself with peers. Apprise the adolescent of the wide variation among teenagers on the rate of growth and development. DIF: Cognitive Level: Applying (Application) REF: p. 125

5. The nurse is preparing to assess a patients abdomen by palpation. How should the nurse proceed? a. Palpation of reportedly tender areas are avoided because palpation in these areas may cause pain. b. Palpating a tender area is quickly performed to avoid any discomfort that the patient may experience. c. The assessment begins with deep palpation, while encouraging the patient to relax and to take deep breaths. d. The assessment begins with light palpation to detect surface characteristics and to accustom the patient to being touched.

ANS: D Light palpation is initially performed to detect any surface characteristics and to accustom the person to being touched. Tender areas should be palpated last, not first. DIF: Cognitive Level: Applying (Application) REF: p. 115

11. The nurse hears bilateral loud, long, and low tones when percussing over the lungs of a 4-year-old child. The nurse should: a. Palpate over the area for increased pain and tenderness. b. Ask the child to take shallow breaths, and percuss over the area again. c. Immediately refer the child because of an increased amount of air in the lungs. d. Consider this finding as normal for a child this age, and proceed with the examination.

ANS: D Percussion notes that are loud in amplitude, low in pitch, of a booming quality, and long in duration are normal over a childs lung. DIF: Cognitive Level: Applying (Application) REF: p. 117

3. A 4-year-old boy is brought to the emergency department by his mother. She says he points to his stomach and says, It hurts so bad. Which pain assessment tool would be the best choice when assessing this childs pain? a. Descriptor Scale b. Numeric rating scale c. Brief Pain Inventory d. Faces Pain ScaleRevised (FPS-R)

ANS: D Rating scales can be introduced at the age of 4 or 5 years. The FPS-R is designed for use by children and asks the child to choose a face that shows how much hurt (or pain) you have now. Young children should not be asked to rate pain by using numbers. DIF: Cognitive Level: Applying (Application) REF: p. 170

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.

ANS: D The disappearance of phase V Korotkoff sounds can be used for the diastolic reading in children, as well as in adults. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 149

15. Before auscultating the abdomen for the presence of bowel sounds on a patient, the nurse should: a. Warm the endpiece of the stethoscope by placing it in warm water. b. Leave the gown on the patient to ensure that he or she does not get chilled during the examination. c. Ensure that the bell side of the stethoscope is turned to the on position. d. Check the temperature of the room, and offer blankets to the patient if he or she feels cold.

ANS: D The examination room should be warm. If the patient shivers, then the involuntary muscle contractions can make it difficult to hear the underlying sounds. The end of the stethoscope should be warmed between the examiners hands, not with water. The nurse should never listen through a gown. The diaphragm of the stethoscope should be used to auscultate for bowel sounds. DIF: Cognitive Level: Applying (Application) REF: p. 117

38. When examining an infant, the nurse should examine which area first? a. Ear b. Nose c. Throat d. Abdomen

ANS: D The least-distressing steps are performed first, saving the invasive steps of the examination of the eye, ear, nose, and throat until last. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 123

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

ANS: D 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. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 138

18. An examiner is using an ophthalmoscope to examine a patients eyes. The patient has astigmatism and is nearsighted. The use of which of these techniques would indicate that the examination is being correctly performed? a. Using the large full circle of light when assessing pupils that are not dilated b. Rotating the lens selector dial to the black numbers to compensate for astigmatism c. Using the grid on the lens aperture dial to visualize the external structures of the eye d. Rotating the lens selector dial to bring the object into focus

ANS: D The ophthalmoscope is used to examine the internal eye structures. It can compensate for nearsightedness or farsightedness, but it will not correct for astigmatism. The grid is used to assess size and location of lesions on the fundus. The large full spot of light is used to assess dilated pupils. Rotating the lens selector dial brings the object into focus. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 119

17. The nurse is preparing to use an otoscope for an examination. Which statement is true regarding the otoscope? The otoscope: a. Is often used to direct light onto the sinuses. b. Uses a short, broad speculum to help visualize the ear. c. Is used to examine the structures of the internal ear. d. Directs light into the ear canal and onto the tympanic membrane.

ANS: D The otoscope directs light into the ear canal and onto the tympanic membrane that divides the external and middle ear. A short, broad speculum is used to visualize the nares. DIF: Cognitive Level: Remembering (Knowledge) REF: p. 119

20. The nurse is preparing to perform a physical assessment. The correct action by the nurse is reflected by which statement? The nurse: a. Performs the examination from the left side of the bed. b. Examines tender or painful areas first to help relieve the patients anxiety. c. Follows the same examination sequence, regardless of the patients age or condition. d. Organizes the assessment to ensure that the patient does not change positions too often.

ANS: D The steps of the assessment should be organized to ensure that the patient does not change positions too often. The sequence of the steps of the assessment may differ, depending on the age of the person and the examiners preference. Tender or painful areas should be assessed last. DIF: Cognitive Level: Applying (Application) REF: p. 121

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.

ANS: D 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. DIF: Cognitive Level: Applying (Application) REF: p. 138

34. When examining an older adult, the nurse should use which technique? a. Avoid touching the patient too much. b. Attempt to perform the entire physical examination during one visit. c. Speak loudly and slowly because most aging adults have hearing deficits. d. Arrange the sequence of the examination to allow as few position changes as possible.

ANS: D When examining the older adult, arranging the sequence of the examination to allow as few position changes as possible is best. Physical touch is especially important with the older person because other senses may be diminished. DIF: Cognitive Level: Applying (Application) REF: p. 125

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.

ANS: D When performing the general survey, the patients arm span (fingertip to fingertip) should equal the patients height. An arm span that is greater than the persons height may indicate Marfan syndrome. The base should be wide when the patient is standing, and an older appearance than the stated age may indicate a history of a chronic illness or chronic alcoholism. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 128

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.

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. DIF: Cognitive Level: Analyzing (Analysis) REF: p. 147