Health Assessment- 9, 10, and 11

C

A patient is being seen in the clinic for complaints of "fainting episodes that started last week." How should the nurse proceed with the examination? A) Take his blood pressure in both arms and thighs. B) Assist him to a lying position and begin taking his blood pressure. C) Record his blood pressure in the lying, sitting, and standing positions. D) Record his blood pressure in the lying and sitting positions and average these numbers. to obtain a mean blood pressure.

B C E

During an admission assessment of a patient with dementia, the nurse assesses for pain because the patient has recently had several falls. Which of these are appropriate for the nurse to assess in a patient with dementia? Select all that apply. A) Ask the patient, "Do you have pain?" B) Assess the patient's breathing independent of vocalization. C) Note whether the patient is calling out, groaning, or crying. D) Have the patient rate pain on a 1 to 10 scale. E) Observe the patient's body language for pacing and agitation.

A

During an examination of a child, the nurse considers that physical growth is the best index of a child's: A) general health. B) genetic makeup. C) nutritional status. D) activity and exercise patterns.

C

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

A D F

During assessment of a patient's pain, the nurse keeps in mind that certain nonverbal behaviors are associated with chronic pain. Which of these behaviors are associated with chronic pain? Select all that apply. A) Sleeping B) Moaning C) Diaphoresis D) Bracing E) Restlessness F) Rubbing

B

How should the nurse perform a triceps skinfold assessment? A) After pinching the skin and fat, apply the calipers vertically to the fat fold. B) Gently pinch the skin and fat on the front of the patient's arm and then apply calipers. C) After applying the calipers, wait 3 seconds before taking a reading. Repeat the procedure three times. D) Instruct the patient to stand with the back to the examiner and arms folded across the chest and pinch the skin on the forearm.

D

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

B

The nurse is assessing the body weight as a percentage of ideal body weight on an adolescent patient who was admitted for suspected anorexia nervosa. The patient's usual weight was 125 pounds, but today she weighs 98 pounds. The nurse calculates the patient's ideal body weight, and reaches which conclusion? A) She is experiencing mild malnutrition. B) She is experiencing moderate malnutrition. C) She is experiencing severe malnutrition. D) Her current weight is still within expected parameters.

A

The nurse is performing a nutritional assessment on an 80-year-old patient. The nurse knows that physiological changes that directly affect the nutritional status of the elderly include: A) slowed gastrointestinal motility. B) hyperstimulation of the salivary glands. C) an increased sensitivity to spicy and aromatic foods. D) decreased gastrointestinal absorption causing esophageal reflux.

C

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) The diastolic blood pressure may not be heard. B) The diastolic blood pressure may be falsely low. C) The systolic blood pressure may be falsely low. D) The systolic blood pressure may be falsely high.

C

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) It is the pressure forcing blood into the tissues, averaged over the cardiac cycle. D) It is an average of the systolic and diastolic blood pressures and reflects tissue perfusion.

A

The nurse is evaluating patients for obesity-related diseases by calculating the waist-to-hip ratios. Which one of these patients would be at increased risk? A) 29-year-old woman whose waist is 33 inches and whose hips are 36 inches B) 32-year-old man whose waist is 34 inches and whose hips are 36 inches C) 38-year-old man whose waist is 35 inches and whose hips are 38 inches D) 46-year-old woman whose waist is 30 inches and whose hips are 38 inches

C

The nurse is assessing a 30-year-old unemployed immigrant from an underdeveloped country who has been in the United States for 1 month. Which of these problems related to his nutritional status might the nurse expect to find? A) Obesity B) Hypotension C) Osteomalacia D) Coronary artery disease

B

The nurse is assessing an 8-year-old child whose growth rate measures below the third percentile for a child his age. He appears much younger than his stated age, and he is chubby with infantile facial features. Which condition does this child have? A) Hypopituitary dwarfism B) Achondroplastic dwarfism C) Marfan syndrome D) Acromegaly

A

The nurse is performing a general survey. Which action is a component of the general survey? A) Observing the patient's body stature and nutritional status B) Interpreting the subjective information the patient has reported C) Measuring the patient's temperature, pulse, respirations, and blood pressure D) Observing specific body systems while performing the physical assessment

B

When assessing a patient's pain, the nurse knows that an example of visceral pain would be: A) hip fracture. B) cholecystitis. C) second-degree burns. D) pain after a leg amputation.

A

When assessing a patient's pulse the nurse should also notice which of these characteristics? A) Force B) Pallor C) Capillary refill time D) Timing in the cardiac cycle

B

A 21-year-old woman has been on a low-protein liquid diet for the past 2 months. She has had adequate calories and appears well nourished. In further assessing her, what would the nurse expect to find? A) Poor skin turgor B) Decreased serum albumin C) Increased lymphocyte count D) Triceps skinfold less than standard

C

When assessing the force, or strength, of a pulse, the nurse recalls that it: A) is usually recorded on a 0- to 2-point scale. B) demonstrates elasticity of the vessel wall. C) is a reflection of the heart's stroke volume. D) reflects the blood volume in the arteries during diastole.

B

When assessing the intensity of a patient's pain, which question by the nurse is appropriate? A) "What makes your pain better or worse?" B) "How much pain do you have now?" C) "How does pain limit your activities?" D) "What does your pain feel like?"

D

When checking for proper blood pressure cuff size, the nurse knows that 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.

C

When evaluating a patient's pain, the nurse knows that an example of acute pain would be: A) arthritic pain. B) fibromyalgia. C) kidney stones. D) low back pain.

A

When evaluating the temperature of older adults, the nurse remembers which aspect about an older adult's body temperature? A) It is lower than that of younger adults. B) It is about the same as that of a young child. C) It depends on the type of thermometer used. D) It varies widely because of less effective heat control mechanisms.

C

When measuring a patient's body temperature, the nurse keeps in mind that body temperature is influenced by: A) constipation. B) patient's emotional state. C) the diurnal cycle. D) the nocturnal cycle.

D

When measuring a patient's weight, the nurse keeps in mind which of these guidelines? A) Always weigh the patient with only his or her undergarments on. B) It does not matter what type of scale is used, 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 this is documented next to the weight. D) Attempt to weigh the patient at approximately the same time of day, if a sequence of weights is necessary.

B

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 have the patient close his or her lips. D) Shake the mercury-in-glass thermometer down to 98° F before taking the temperature.

C

Which of these conditions is due to an inadequate intake of both protein and calories? A) Obesity B) Bulimia C) Marasmus D) Kwashiorkor

C

Which of these interventions is most appropriate when the nurse is planning nutritional interventions for a healthy, active 74-year-old woman? A) Decrease the amount of carbohydrates to prevent lean muscle catabolism. B) Increase the amount of soy and tofu in her diet to promote bone growth and reverse osteoporosis. C) Decrease the number of calories she is eating because of the decrease in energy requirements from loss of lean body mass. D) Increase the number of calories she is eating because of the increased energy needs of the elderly.

B

Which of these specific measurements is the best index of a child's general health? A) Vital signs B) Height and weight C) Head circumference D) Chest circumference

A

Which technique is correct when the nurse is assessing the radial pulse of a patient? Count the: A) pulse for 1 minute if the rhythm is irregular. B) pulse for 15 seconds and multiply by four, if the rhythm is regular. C) initial pulse for a full 2 minutes to detect any variation in amplitude. D) pulse for 10 seconds and multiply by six, if the patient has no history of cardiac abnormalities.

B

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

D

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

C

A 65-year-old man is brought to the emergency department after he was found dazed and incoherent, alone in his apartment. He has an enlarged liver and is moderately dehydrated. When evaluating his serum albumin level, the nurse must keep in mind that: A) serum albumin levels will increase as liver function decreases. B) serum albumin levels are a sensitive measure of early protein malnutrition. C) low serum albumin levels may be caused by reasons other than protein-calorie malnutrition. D) the results of the serum albumin measurement along with the patient's hemoglobin level should be considered.

B

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) This is a normal response due to changes in the patient's position. B) The change in blood pressure readings is called orthostatic hypotension. C) The blood pressure reading in the lying position is within normal limits. D) The change in blood pressure reading is considered within normal limits for the patient's age.

A

A 75-year-old man has a history of hypertension and was recently changed to a new antihypertensive drug. He reports feeling dizzy at times. How should the nurse evaluate his blood pressure? A) Assess blood pressure and pulse in the supine, sitting, and standing positions. B) Have the patient walk around the room and assess his blood pressure after activity. C) Assess his blood pressure and pulse at the beginning and end of the examination. D) Take the blood pressure on the right arm and then 5 minutes later take the blood pressure on the left arm.

B

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 systolic and diastolic blood pressures. D) Changes in the body's temperature regulatory mechanism leave the aging person more likely to develop a fever.

C

The mother of an 8-year-old boy is concerned about the amount of weight her son has gained. To determine whether this is a problem, the nurse will measure: A) arm span. B) waist-to-hip ratio. C) skinfold thickness. D) mid-upper arm circumference.

B

The nurse has collected the following information on a patient: palpated blood pressure—180; auscultated blood pressure—170/100 mm Hg; apical pulse—60; radial pulse—70. What is the patient's pulse pressure? A) 10 B) 70 C) 80 D) 100

D

The nurse in a family practice clinic is reviewing the patients scheduled for appointments. Which of these statements is true regarding routine laboratory testing in the following individuals? A) In pregnancy, no laboratory testing is needed unless problems with the pregnancy are suspected. B) In the elderly, laboratory values regarding cholesterol and triglycerides are the most important because of the risk of disease. C) Routine laboratory testing is not necessary during adolescence, except in cases of illness. D) Laboratory tests for iron and lead levels should be assessed at 9 to 12 months.

B C

The nurse is assessing an obese patient for signs of metabolic syndrome. This condition is diagnosed when three or more certain risk factors are present. Which of these assessment findings are risk factors for metabolic syndrome? Select all that apply. A) Fasting plasma glucose level less than 100 mg/dL B) Fasting plasma glucose level greater than or equal to 110 mg/dL C) Blood pressure reading of 140/90 mm Hg D) Blood pressure reading of 110/80 mm Hg E) Triglyceride level of 120 mg/dL

B

The nurse is assessing the vital signs of a 20-year-old male marathon runner and documents the following vital signs: temperature—97 F; pulse—48 beats per minute; respirations—14 per minute; blood pressure—104/68 mm Hg. Which statement is true about these results? A) The patient is experiencing tachycardia. B) These are normal vital signs for a healthy, athletic adult. C) The patient's pulse rate is not normal—his physician should be notified. D) On the basis of today's readings, the patient should return to the clinic in 1 week.

A

The nurse is assessing the vital signs of a 3-year-old patient who appears to have an irregular respiratory pattern. How should the nurse assess this child's respirations? A) Count the respirations for 1 full minute, noticing rate and rhythm. B) Check the child's pulse and respirations simultaneously for 30 seconds. C) Check the child's respirations for a minimum of 5 minutes to identify any variations in respiratory pattern. D) Count the patient's respirations for 15 seconds and multiply by four to obtain the number of respirations per minute.

C

The nurse is concerned about the skeletal protein reserves of a patient who has been hospitalized frequently for chronic lung disease. Which of these measurements would be necessary to include in the assessment? A) Body mass index B) Weight and height C) Mid-arm muscle area D) Ideal body weight and frame size

C

The nurse knows that which statement is true regarding the pain experienced by infants? A) Pain in infants can only be assessed by physiologic changes, such as increased heart rate. B) The Faces Pain Scale—revised (FPS-R) can be used to assess pain in infants. C) A procedure that induces pain in adults will also induce pain in the infant. D) Infants feel pain less than adults do.

B

The nurse needs to perform anthropometric measures of an 80-year-old man who is confined to a wheelchair. Which of the following is true in this situation? A) Changes in fat distribution will affect the waist-to-hip ratio. B) Height measurements may not be accurate because of changes in bone. C) Declining muscle mass will affect the triceps skinfold measure. D) Mid-arm circumference is difficult to obtain because of loss of skin elasticity.

B

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.

C

The nurse should measure rectal temperatures in which of these patients? A) School-age child B) Elderly adult C) Comatose adult D) Patient receiving oxygen by nasal cannula

B

The nurse will perform a palpated pressure before auscultating blood pressure. The reason for this is to: A) hear the Korotkoff sounds more clearly. B) detect the presence of an auscultatory gap. C) avoid missing a falsely elevated blood pressure. D) identify phase IV of the Korotkoff sounds more readily.

A

To accurately assess a rectal temperature on 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.

D

To assess the muscle mass and fat stores on a 40-year-old woman, the nurse would use: A) triceps skinfold. B) mid-thigh muscle area. C) percent ideal body weight. D) mid-upper arm circumference.

D

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.

B

When assessing an older adult, the nurse keeps in mind that 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

D

While measuring a patient's blood pressure, the nurse recalls that certain factors help to determine blood pressure, such as: A) pulse rate. B) pulse pressure. C) vascular output. D) peripheral vascular resistance.

A B D E

While measuring a patient's blood pressure, the nurse uses 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 wrapped loosely around the arm. E) The person is sitting with his or her legs crossed. F) The nurse does not inflate the cuff high enough.

B

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: A) after menopause, blood pressure in women is usually lower than in men. B) a black adult's blood pressure is usually higher than that of whites 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 teen's blood pressure reading will be lower than that of an adult.

C

A patient's blood pressure is 118/82. He asks the nurse to explain "what the numbers mean." The nurse's best reply would be: A) "The numbers are within normal range and 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 main thing to be concerned about is the top number, or systolic blood pressure."

A

After completing a diet assessment on a 30-year-old woman, the nurse suspects that she may be deficient in iron. Laboratory studies to obtain to verify this condition would be: A) hemoglobin and hematocrit. B) cholesterol and triglycerides. C) urinalysis. D) serum albumin.

B

The nurse is counting an infant's respirations. Which technique is correct? A) Watch the chest rise and fall. B) Watch the abdomen for movement. C) Place a hand across the infant's chest. D) Use a stethoscope to listen to the breath sounds.

B

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

C

The nurse is helping another nurse to take a blood pressure reading on a patient's thigh. Which action is correct regarding thigh pressure? A) Auscultate either the popliteal or femoral vessels 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 compare it with the thigh pressure. D) The thigh pressure is lower than that in the arm due to distance away from the heart and the size of the popliteal vessels.

D

The nurse is measuring a patient's frame size. Which of these statements best describes the correct technique for measuring frame size? A) With the patient standing, measure the distance from the top of the head to the back of the heel. B) With the patient in a sitting position, measure the distance from the condyle of the humerus to the clavicle. C) With the patient's right arm extended forward and the elbow extended, measure the distance from fingertips to the condyle of the humerus. D) With the right arm extended forward and the elbow bent, use the calipers to measure the distance between the condyles of the humerus.

D

The nurse is preparing to measure fat and lean body mass and bone mineral density. Which tool is appropriate? A) Measuring tape B) Skin fold calipers C) Bioelectrical impedance analysis D) Dual-energy x-ray absorptiometry

C

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) Measure the infant's length by using a tape measure. B) Weigh the infant by placing him on an electronic standing scale. C) Measure chest circumference at the nipple line with a tape measure. D) Measure the head circumference by wrapping the tape measure over the nose and cheekbones.

A

The nurse is preparing to measure the vital signs of a 6-month-old infant. Which action by the nurse is correct? A) Measure respirations and then pulse and temperature. B) Measure vital signs more frequently than in an adult. C) Explain procedures and encourage the infant to handle the equipment. D) Allow the infant to become familiar with the nurse by performing the physical examination first and then measuring the vital signs.

D

The nurse is reviewing laboratory studies on a patient who may have protein malnutrition. Which of these measurements is an early indicator of protein malnutrition? A) Serum albumin B) Serum creatinine C) Nitrogen balance D) Serum transferrin

D

The nurse is reviewing principles of pain. Which type of pain is due to an abnormal processing of the pain impulse through the peripheral or central nervous system? A) Visceral B) Referred C) Cutaneous D) Neuropathic

A

The nurse is reviewing the principles of nociception. During which phase of nociception does the conscious awareness of a painful sensation occur? A) Perception B) Modulation C) Transduction D) Transmission

C

The nurse is taking temperatures in a clinic with a tympanic thermometer. Which statement is true regarding use of the tympanic thermometer? 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) There is a reduced risk of cross-contamination compared with the rectal route. D) The tympanic membrane most accurately reflects the temperature in the ophthalmic artery.

A

The nurse knows that one advantage of the tympanic thermometer is that: A) its rapid measurement is useful for uncooperative younger children. B) it is the most accurate method for measuring temperature in newborn infants. C) it is an inexpensive means of measuring temperature. D) studies strongly support use of the tympanic route in children under age 6 years.