NUR 3121 Health Assessment Unit #2 Exam
Advantages of Breastfeeding
1. Fewer food allergies and intolerances 2. Reduced likelihood of overfeeding 3. Less cost than commercial infant formulas 4. Increased mother-infant interaction time
Cardinal features of a successful long-term weight loss plan
1. Getting regular physical exercise 2. Eating a low-calorie, low fat diet. 3. Monitoring daily food intake and weight.
Nutrition screening
1st step in assessing nutritional status, required for all patients in all heath care settings within 24 hours of admission. Malnutrition Screening Tool Mini Nutritional Assessment- used for older adults in long-term care and community settings
When assessing the intensity of a patient's pain, which question by the nurse is appropriate?
ANS: "How much pain do you have now?" Asking the patient "how much pain do you have?" is an assessment of the intensity of a patient's pain; various intensity scales can be used. Asking what makes one's pain better or worse assesses alleviating or aggravating factors. Asking if pain limits one's activities assesses the degree of impairment and quality of life. Asking "what does your pain feel like" assesses the quality of pain.
Which statement indicates that the nurse understands the pain experienced by an elderly person?
ANS: "Pain indicates pathology or injury and is not a normal process of aging." Pain indicates pathology or injury and should never be considered something that an elderly person should expect or tolerate. Pain is not a normal process of aging, and there is no evidence that pain perception is reduced with aging.
The nurse will use which technique of assessment to determine the presence of crepitus, swelling, and pulsations?
ANS: Palpation Palpation applies the sense of touch to assess these factors: 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 presence of tenderness or pain.
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:
ANS: "The top number is the systolic blood pressure and reflects the pressure of the blood against the arteries when the heart contracts." 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 exerts constantly in between each contraction. The nurse should answer the patient's question and use terms he can understand.
When assessing the quality of a patient's pain, the nurse should ask which question?
ANS: "What does your pain feel like?" To assess the quality of a person's pain, have the patient describe the pain in his or her own words.
During the examination, it is often appropriate to offer some brief teaching about the patient's body or the examiner's findings. Which of these statements by the nurse is most appropriate?
ANS: "Your pulse is 80 beats per minute. This is within the normal range." Sharing of some information builds rapport as long as the patient is able to understand the terminology.
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 patient's blood pressure?
ANS: 200/92 In adults, the last audible sound indicates diastolic pressure best. When a variance greater than 10 to 12 mm Hg exists between phases IV and V, record both phases along with the systolic reading (e.g., 142/98/80).
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.
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?
ANS: 70 Pulse pressure is the difference between systolic and diastolic blood pressure (170 - 100 = 70) and reflects the stroke volume.
The nurse knows that which statement is true regarding the pain experienced by infants?
ANS: A procedure that induces pain in adults will also induce pain in the infant. If a procedure or disease process causes pain in an adult, then it will also cause pain in an infant. Physiologic changes cannot be used exclusively to confirm or deny pain because other factors, such as medications, fluid status, or stress may cause physiologic changes. The Faces Pain Scale—Revised can be used starting at around age 4 years.
When examining an infant, the nurse should examine which area first?
ANS: Abdomen Perform the least distressing steps first. Save the invasive steps of examination of the eye, ear, nose, and throat until last.
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?
ANS: Achondroplastic dwarfism Hypopituitary dwarfism is caused by deficiency in growth hormone in childhood and results in retardation of growth below the third percentile, delayed puberty, and other problems. The child's appearance fits this description. Achondroplastic dwarfism is a genetic disorder resulting in characteristic deformities; Marfan syndrome is an inherited connective tissue disorder characterized by tall, thin stature and other features. Acromegaly is the result of excessive secretion of growth hormone in adulthood. See Table 9-5, Abnormalities in Body Height and Proportion, for more information.
A patient is complaining of severe knee pain after twisting it during a basketball game and is requesting pain medication. Which action by the nurse is appropriate?
ANS: Administer pain medication and then proceed with the assessment. According to the American Pain Society (1992), "In cases in which the cause of acute pain is uncertain, establishing a diagnosis is a priority, but symptomatic treatment of pain should be given while the investigation is proceeding. With occasional exceptions, (e.g., the initial examination of the patient with an acute condition of the abdomen), it is rarely justified to defer analgesia until a diagnosis is made. In fact, a comfortable patient is better able to cooperate with diagnostic procedures."
A 2-year-old child has been brought to the clinic for a well-child check-up. The best way for the nurse to begin the assessment is reflected by which statement?
ANS: Allow the child to keep a security object such as a toy or blanket during the examination. The best place to examine the toddler is on the parent's lap. Toddlers understand symbols, so a security object is helpful. Initially, focus more on the parent. This allows the child to gradually adjust and become familiar with you. A 2-year-old child does not like to take off his or her clothes. Have the parent undress one body part at a time.
The nurse is conducting a health fair for older adults. Which statement is true regarding vital sign measurements in aging adults?
ANS: An increased respiratory rate and a shallower inspiratory phase are expected findings. 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 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 aging person less likely to have fever, but at a greater risk for hypothermia.
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?
ANS: Appear unhurried and confident when examining him. Anxiety can be reduced by an examiner who is confident, self-assured, considerate, and unhurried. Familiar and relatively nonthreatening actions, such as measuring the person's vital signs, will gradually accustom the person to the examination.
The nurse is performing a general survey. Which finding is considered normal?
ANS: Arm span (fingertip to fingertip) equals height. When performing the general survey, the patient's arm span (fingertip to fingertip) should equal the patient's height. An arm span greater than the person's height may indicate Marfan syndrome. The base should be wide when standing, and an appearance older than the stated age may indicate a history of a chronic illness or chronic alcoholism.
When examining an aging adult, the nurse should use which technique?
ANS: Arrange the sequence to allow as few position changes as possible. When examining the aging adult, it is best to arrange the sequence of the examination to allow as few position changes as possible. Physical touch is especially important with the aging person because other senses may be diminished.
During auscultation of a patient's heart sounds, the nurse hears an unfamiliar sound. What should the nurse do next?
ANS: Ask another nurse to double-check the finding. 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 to identify the unfamiliar sound.
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?
ANS: Assess blood pressure and pulse in the supine, sitting, and standing positions. 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 are recorded in the supine, sitting, and standing positions.
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.
ANS: Assess the patient's breathing independent of vocalization., Note whether the patient is calling out, groaning, or crying., Observe the patient's body language for pacing and agitation. Patients with dementia may say "no" when, in reality, they are very uncomfortable because words have lost their meaning. Patients with dementia become less able to identify and describe pain over time, even though pain is still present. People with dementia communicate pain through their behaviors. Agitation, pacing, and repetitive yelling may indicate pain and not a worsening of the dementia. See Figure 10-10 for the Pain Assessment in Advanced Dementia (PAINAD) Scale, which may also be used to assess pain in persons with dementia.
The nurse is examining an infant and prepares to elicit the Moro reflex at which time during the examination?
ANS: At the end of the examination Elicit the Moro or "startle" reflex at the end of the examination because it may cause the infant to cry.
Observing the patient's body stature and nutritional status
ANS: Attempt to weigh the patient at approximately the same time of day, if a sequence of weights is necessary. 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 aim for approximately the same time of day and type of clothing worn each time.
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?
ANS: Auscultate an apical rate for 1 minute and assess for any normal irregularities, such as sinus arrhythmia. Palpate or auscultate an apical rate with infants and toddlers. Count the pulse for 1 full minute to take into account normal irregularities, such as sinus arrhythmia. Children younger than 3 years have such small arm vessels that it is difficult to hear Korotkoff sounds with a stethoscope; instead, the nurse should use either an electronic blood pressure device that uses oscillometry or a Doppler ultrasound device to amplify the sounds.
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?
ANS: Auscultate the lungs and heart while the infant is still sleeping. 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 and should be performed at the end of the examination.
Direct observation
Can detect problems not readily identified through standard nutritional interviews.
The nurse is examining a 2-year-old child and asks, "May I listen to your heart now?" Which critique of the nurse's technique is most accurate?
ANS: Children at this age like to say "No." The examiner should not offer a choice when there is none. Children at this age like to say "No." Do not offer a choice when there really is none. 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?"
The nurse should measure rectal temperatures in which of these patients?
ANS: Comatose adult Rectal temperatures should be taken when the other routes are not practical, such as for comatose or confused persons, for persons in shock, or for those who cannot close the mouth because of breathing or oxygen tubes, wired mandible, or other facial dysfunctions.
The nurse hears bilateral louder, longer, and lower tones when percussing over the lungs of a 4-year-old child. What should the nurse do next?
ANS: Consider this a normal finding for a child this age and proceed with the examination. Percussion notes that are louder in amplitude, lower in pitch, of a booming quality, and longer in duration are normal over a child's lung.
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?
ANS: Count the respirations for 1 full minute, noticing rate and rhythm. Count respirations for 1 full minute if an abnormality is suspected. The other responses are not correct actions.
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?
ANS: Cushing syndrome 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.
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?
ANS: Increased blood pressure and pulse 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.
The nurse is preparing to assess a hospitalized patient who is experiencing significant shortness of breath. How should the nurse proceed with the assessment?
ANS: Examine body areas appropriate to the problem and then complete the assessment after the problem has resolved. It may be necessary in this situation to alter the position of the patient during the examination and to collect a mini data base by examining the body areas appropriate to the problem. You may return later to complete the assessment after the distress is resolved.
When assessing a patient's pulse the nurse should also notice which of these characteristics?
ANS: Force The pulse is assessed for rate, rhythm, and force.
The nurse is preparing to examine a 4-year-old child. Which action is appropriate for this age group?
ANS: Give the child feedback and reassurance during the examination. With preschool children use short, simple explanations. Children at this age are usually willing to undress. Examination of the head should be performed last. During the examination give the preschooler needed feedback and reassurance.
Which of these specific measurements is the best index of a child's general health?
ANS: Height and weight Physical growth, measured by height and weight, is the best index of a child's general health.
The nurse is helping another nurse to take a blood pressure reading on a patient's thigh. Which action is correct regarding thigh pressure?
ANS: If the blood pressure in the arm is high in an adolescent, then compare it with the thigh pressure. When blood pressure measured at the arm is excessively high, particularly in adolescents and young adults, compare it 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, but if coarctation of the artery is present, then arm pressures are higher than thigh pressures.
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?
ANS: Increase the amount of strength used when attempting to percuss over the abdomen. The thickness of the person's body wall will be a factor. The nurse will need 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.
The nurse is taking an initial blood pressure on a 72-year-old patient with documented hypertension. How should the nurse proceed?
ANS: Inflate the blood pressure cuff 30 mm Hg above the point at which the palpated pulse disappears. An auscultatory gap occurs in about 5% of the people, most often in those with hypertension. To check for the presence of an auscultatory gap, inflate the cuff 20 to 30 mm Hg beyond the point at which the palpated pulse disappeared.
The nurse is preparing to perform a physical assessment. Which statement is true about the inspection phase of the physical assessment?
ANS: Inspection takes time and reveals a surprising amount of information. 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 much more than a "quick glance."
When evaluating the temperature of older adults, the nurse remembers which aspect about an older adult's body temperature?
ANS: It is lower than that of younger adults. In older adults, temperature is usually lower than in other age groups, with a mean temperature of 36.2° C (97.2° F).
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?
ANS: It is the pressure forcing blood into the tissues, averaged over the cardiac cycle. The MAP is the pressure forcing 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. It is a value closer to diastolic pressure plus one third the pulse pressure.
The nurse is preparing to examine a 6-year-old child. Which action is most appropriate?
ANS: Keep in mind that a child this age will have a sense of modesty. A 6-year-old child has a sense of modesty. The child should undress himself or herself, leaving underpants on, and use a gown or drape. A school-age child is curious to know how equipment works, and the sequence should progress from head to toes.
Which demonstrates an understanding of how to use a thrmometer?
ANS: Leave the thermometer in place 3 to 4 minutes if the patient is afebrile. Leave the thermometer in place 3 to 4 minutes if the person is afebrile and up to 8 minutes if the person is febrile. Wait 15 minutes if the person has just taken hot or iced liquids and 2 minutes if he or she has just smoked.
The nurse is preparing to measure the length, weight, chest, and head circumference of a 6-month-old infant. Which measurement technique is correct?
ANS: Measure chest circumference at the nipple line with a tape measure. To measure chest circumference, encircle the tape around the chest at the nipple line. 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, at the prominent frontal and occipital bones; the widest span is correct.
The nurse is preparing to measure the vital signs of a 6-month-old infant. Which action by the nurse is correct?
ANS: Measure respirations and then pulse and temperature. With an infant, reverse the order of vital sign measurement 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. Measure vital signs with the same purpose and frequency as you would in an adult.
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?
ANS: Neuropathic Neuropathic pain implies an abnormal processing of the pain message. The other types of pain are named according to their sources.
The nurse is performing a general survey. Which action is a component of the general survey?
ANS: Observing the patient's body stature and nutritional status The general survey is a study of the whole person that includes observation of physical appearance, body structure, mobility, and behavior.
In a patient with acromegaly, the nurse will expect to discover which assessment findings?
ANS: Overgrowth of bone in the face, head, hands, and feet Excessive secretions of growth hormone in adulthood after normal completion of body growth causes overgrowth of bones in the face, head, hands, and feet but no change in height.
The nurse would use bimanual palpation technique in which situation?
ANS: Palpating the kidneys and uterus 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.
Which of these techniques uses the sense of touch to assess texture, temperature, moisture, and swelling when the nurse is assessing a patient?
ANS: Palpation 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.
The nurse is reviewing the principles of nociception. During which phase of nociception does the conscious awareness of a painful sensation occur?
ANS: Perception Perception is the third phase of nociception and indicates the conscious awareness of a painful sensation. During this phase, the sensation is recognized by higher cortical structures and identified as pain.
A patient has suddenly developed shortness of breath and appears to be in significant respiratory distress. After putting a call in to the physician and placing the patient on oxygen, which of these is the best action for the nurse to take when assessing the patient further?
ANS: Percuss the thorax bilaterally, noting any differences in percussion tones. Percussion is always available, portable, and gives instant feedback regarding changes in underlying tissue density, which may yield clues of the patient's physical status.
A patient's weekly blood pressure readings for 2 months have ranged between 124/84 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?
ANS: Prehypertension According to the JNC-VII guidelines, prehypertension blood pressure readings are systolic 120 to 139 mm Hg or diastolic 50 to 89 mm Hg.
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?
ANS: Preschool child When assessing preschool children, it is helpful to use games or allow them to play with the equipment to reduce their fears. Such games are not appropriate for the other age groups listed.
The nurse is examining a patient who is complaining of "feeling cold." Which is a mechanism of heat loss in the body?
ANS: Radiation The body maintains a steady temperature through a thermostat, or feedback mechanism, 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).
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?
ANS: Record his blood pressure in the lying, sitting, and standing positions. If the person is known to have hypertension, is taking antihypertensive medications, or reports a history of fainting or syncope, then take the blood pressure reading in three positions: lying, sitting, and standing.
An examiner is using an ophthalmoscope to examine a patient's eyes. The patient has astigmatism and is nearsighted. The use of which of these techniques would indicate that the examination is being performed correctly?
ANS: Rotating the lens selector dial to bring the object into focus 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.
A patient has had arthritic pain in her hips for several years since a hip fracture. She is able to move around in her room and has not offered any complaints so far this morning. However, when asked, she states that her pain is "bad this morning" and rates it at an 8 on a 1 to 10 scale. What does the nurse suspect?
ANS: She has experienced chronic pain for years and has adapted to it. Persons with chronic pain typically try to give little indication that they are in pain and, over time, adapt to the pain. As a result, they are at risk for underdetection.
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.
ANS: Sleeping, Bracing, Rubbing Behaviors that have been associated with chronic pain include bracing, rubbing, diminished activity, sighing, and change in appetite. In addition, those with chronic pain may sleep in an attempt at distraction. The other behaviors are associated with acute pain.
Which of these statements is true regarding the use of standard precautions in the health care setting?
ANS: Standard precautions are intended for use with all patients regardless of their risk or presumed infection status. Standard precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources. They are intended for use for all patients, regardless of their risk or presumed infection status. They apply to blood and all other body fluids, secretions and excretions except sweat—regardless 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.
The nurse is preparing to assess a patient's abdomen by palpation. How should the nurse proceed?
ANS: Start with light palpation to detect surface characteristics and to accustom the patient to being touched. Light palpation is performed initially to detect any surface characteristics and to accustom the person to being touched. Tender areas should be palpated last, not first.
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 child's pain?
ANS: The Faces Pain Scale—Revised (FPS-R) Rating scales can be introduced at the age of 4 or 5 years. The Faces Pain Scale—Revised (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.
While auscultating heart sounds, the nurse hears a murmur. Which of these should be used to assess this murmur?
ANS: The bell of the stethoscope 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.
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?
ANS: The change in blood pressure readings is called orthostatic hypotension. 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.
The nurse is assessing children in a pediatric clinic. Which statement is true regarding measurement of blood pressure in children?
ANS: The disappearance of phase V Korotkoff sounds can be used for the diastolic reading in children. The disappearance of phase V Korotkoff sounds can be used for the diastolic reading in children as well as in adults.
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.
ANS: The person supports his or her own arm during the blood pressure reading., The blood pressure cuff is too narrow for the extremity., The cuff is wrapped loosely around the arm., The person is sitting with his or her legs crossed. Refer to Table 9-5, Common Errors in Blood Pressure Measurement. Several factors can result in blood pressure readings that are too high or too low. Having the patient's arm held above the level of the heart is one part of the correct technique.
The nurse is assessing an 80-year-old male patient. Which assessment findings would be considered normal?
ANS: The presence of kyphosis and flexion in the knees and hips Changes that occur in the aging person include more prominent bony landmarks, decreased body weight (especially in males), 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.
The nurse is teaching a class on basic assessment skills. Which of these statements is true regarding the stethoscope and its use?
ANS: The stethoscope does not magnify sound but does block out extraneous room noise. The stethoscope does not magnify sound but does block out extraneous room sounds. The slope of the earpieces should point forward toward the examiner's nose. Longer tubing will distort sound. The fit and quality of the stethoscope are important.
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?
ANS: The systolic blood pressure may be falsely low. If an auscultatory gap is undetected, then a falsely low systolic or falsely high diastolic reading may result. This is common in patients with hypertension.
When checking for proper blood pressure cuff size, the nurse knows that which guideline is correct?
ANS: The width of the rubber bladder should equal 40% of the arm circumference. The width of the rubber bladder should equal 40% of the circumference of the person's arm. The length of the bladder should equal 80% of this circumference.
The nurse is taking temperatures in a clinic with a tympanic thermometer. Which statement is true regarding use of the tympanic thermometer?
ANS: There is a reduced risk of cross-contamination compared with the rectal route. The tympanic membrane thermometer is a noninvasive, nontraumatic device that is extremely quick and efficient. There is minimal chance of cross-contamination with the tympanic thermometer because the ear canal is lined with skin, not mucous membrane.
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?
ANS: These are normal vital signs for a healthy, athletic adult. In the adult, a heart rate less than 50 beats per minute is called bradycardia. This occurs normally in the well-trained athlete whose heart muscle develops along with the skeletal muscles.
The nurse is preparing to palpate the thorax and abdomen of a patient. Which of these statements describes correct technique for this procedure? Select all that apply.
ANS: Warm the hands first before touching the patient., Start with light palpation to detect surface characteristics., Use the fingertips to examine skin texture, swelling, pulsation, and presence of lumps., Identify any tender areas, and palpate them last. Always warm the hands before beginning palpation. Use intermittent pressure rather than one long continuous palpation; identify any tender areas, and palpate them last. Fingertips are used to examine skin texture, swelling, pulsation, and presence of lumps. Use the dorsa (backs) of the hands to assess skin temperature because the skin on the dorsa is thinner than on the palms.
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?
ANS: Wash hands before and after every physical patient encounter. 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 there is potential contact with any body fluids.
The nurse is examining a patient's lower leg and notices a draining ulceration. Which of these actions is most appropriate in this situation?
ANS: Wash hands, put on gloves, and continue with the examination of the ulceration. The examiner should wear gloves when there is potential contact with any body fluids. In this situation, the nurse should wash his or her hands, put on gloves, and continue examining the ulceration.
The nurse is counting an infant's respirations. Which technique is correct?
ANS: Watch the abdomen for movement. Watch the infant's abdomen for movement because the infant's respirations are normally more diaphragmatic than thoracic. The other responses do not reflect correct technique.
When assessing an older adult, the nurse keeps in mind that which vital sign changes occur with aging?
ANS: Widened pulse pressure With aging 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.
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:
ANS: a black adult's blood pressure is usually higher than that of whites of the same age. In the United States, a black adult's blood pressure is usually higher than that of a white's 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 obese people are usually higher than in those who are not overweight. Normally, a gradual rise occurs through childhood and into the adult years.
During an examination of a patient's abdomen, the nurse notes that the abdomen is rounded and firm to the touch. During percussion, the nurse notes a drum-like quality of the sound across the quadrants. This type of sound indicates:
ANS: air-filled areas. A musical or drum-like sound (tympany) is the sound heard when percussion occurs over an air-filled viscus, such as the stomach or intestines.
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:
ANS: yield a falsely high blood pressure. Using a cuff that is too narrow yields a falsely high blood pressure because it takes extra pressure to compress the artery.
A student is late for his appointment and has rushed across campus to the health clinic. Before assessing his vital signs, the nurse should:
ANS: allow him 5 minutes to relax and rest before checking his vital signs. 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 before measuring his blood pressure.
The nurse keeps in mind that the most important reason to share information and offer brief teaching while performing the physical examination is to help:
ANS: build rapport and increase the patient's confidence in the examiner. Sharing of information builds rapport and increases the patient's confidence in the examiner. It also gives the patient a little more control in a situation in which it is easy to feel completely helpless.
Before auscultating the abdomen for the presence of bowel sounds on a patient, the nurse should:
ANS: check the temperature of the room and offer blankets to the patient if he or she feels cold. 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 examiner's 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.
When assessing a patient's pain, the nurse knows that an example of visceral pain would be:
ANS: cholecystitis. Visceral pain originates from the larger interior organs, such as the gallbladder, liver, or kidneys.
A 1-month-old infant has a head measurement of 34 cm and has a chest circumference of 32 cm. Based on interpretation of these findings, the nurse would:
ANS: consider this a normal finding for a 1-month-old infant. The newborn's head measures about 32 to 38 cm and is about 2 cm larger than the chest circumference. Between 6 months and 2 years, both measurements are about the same, and after age 2 years, the chest circumference is greater than the head circumference.
When assessing the pulse of a 6-year-old boy, the nurse notices that his heart rate varies with his respiratory cycle, speeding up at the peak of inspiration and slowing to normal with expiration. The nurse's next action would be to:
ANS: consider this a normal finding in children and young adults. Sinus arrhythmia is commonly found in children and young adults. Here the heart rate varies with the respiratory cycle, speeding up at the peak of inspiration and slowing to normal with expiration.
When percussing over the liver of a patient, the nurse notices a dull sound. The nurse should:
ANS: consider this a normal finding. Percussion over relatively dense organs, such as the liver or spleen, will produce a dull sound. The other responses are not correct.
A patient has been admitted to the hospital with vertebral fractures related to osteoporosis. She is in extreme pain. This type of pain would be classified as:
ANS: deep somatic. Deep somatic pain comes from sources such as the blood vessels, joints, tendons, muscles, and bone. Referred pain is felt at one site but originates from another location. Cutaneous pain is derived from the skin surface and subcutaneous tissues. Visceral pain originates from the larger, interior organs.
The nurse is preparing to percuss the abdomen of a patient. The purpose of the percussion is to assess the underlying tissue:
ANS: density. Percussion yields a sound that depicts the location, size, and density of the underlying organ. Turgor and texture are assessed with palpation.
The nurse will perform a palpated pressure before auscultating blood pressure. The reason for this is to:
ANS: detect the presence of an auscultatory gap. Inflation of the cuff 20 to 30 mm Hg beyond the point at which a palpated pulse disappears will avoid missing an auscultatory gap, which is a period when the Korotkoff sounds disappear during auscultation.
The nurse is preparing to use an otoscope for an examination. Which statement is true regarding the otoscope? The otoscope:
ANS: directs light into the ear canal and onto the tympanic membrane. 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.
The nurse is assessing a patient's skin during an office visit. What is the best technique to use to best assess the patient's skin temperature? Use the:
ANS: dorsal surface of the hand because the skin is thinner than on the palms. The dorsa (backs) of hands and fingers are best for determining temperature because the skin there is thinner than on the palms. Fingertips are best for fine, tactile discrimination; the other responses are not useful for palpation.
During an examination of a child, the nurse considers that physical growth is the best index of a child's:
ANS: general health. Physical growth is the best index of a child's general health; recording the child's height and weight help to determine normal growth patterns.
When preparing to perform a physical examination on an infant, the nurse should:
ANS: have the parent remove all clothing except the diaper on a boy. The parent should always be present to increase the child's feeling of security and to understand normal growth and development. 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.
When performing a physical assessment, the technique the nurse will always use first is:
ANS: inspection. 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, where 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.
When assessing the force, or strength, of a pulse, the nurse recalls that it:
ANS: is a reflection of the heart's stroke volume. The heart pumps an amount of blood (the stroke volume) into the aorta. The force flares the arterial walls and generates a pressure wave, which is felt in the periphery as the pulse.
The nurse is preparing to use a stethoscope for auscultation. Which statement is true regarding the diaphragm of the stethoscope? The diaphragm:
ANS: is used to listen for high-pitched sounds. The diaphragm of the stethoscope is best for listening to high-pitched sounds such as breath, bowel, and normal heart sounds. It should be held firmly against the person's 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.
The nurse knows that one advantage of the tympanic thermometer is that:
ANS: its rapid measurement is useful for uncooperative younger children. The tympanic thermometer (TMT) is useful for younger children who may not cooperate for oral temperatures and fear rectal temperatures. Keep in mind that TMT use with newborn infants and young children is conflicting.
When evaluating a patient's pain, the nurse knows that an example of acute pain would be:
ANS: kidney stones. Acute pain is short-term and dissipates after an injury heals, such as with kidney stones. The other conditions are examples of chronic pain where the pain continues for 6 months or longer and does not stop when the injury heals.
The nurse is preparing to perform a physical assessment. The correct action by the nurse is reflected by which statement? The nurse:
ANS: organizes the assessment so that the patient does not change positions too often. The steps of the assessment should be organized so 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 examiner's preference. Tender or painful areas should be assessed last.
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? The nurse:
ANS: percusses once over each area. For percussion, the nurse should percuss two times over each location. The striking finger should be lifted off quickly 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 it is used to make the strikes, not the arm.
While measuring a patient's blood pressure, the nurse recalls that certain factors help to determine blood pressure, such as:
ANS: peripheral vascular resistance. The level of blood pressure is determined by five factors: cardiac output, peripheral vascular resistance, volume of circulating blood, viscosity, and elasticity of vessel walls.
When examining a 16-year-old male teenager, the nurse should:
ANS: provide feedback that his body is developing normally and discuss the wide variation among teenagers on the rate of growth and development. 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 himself or herself to peers. Apprise the adolescent of the wide variation among teenagers on the rate of growth and development.
Which technique is correct when the nurse is assessing the radial pulse of a patient? Count the:
ANS: pulse for 1 minute if the rhythm is irregular. Recent research suggests that the 30-second interval multiplied by two is the most accurate and efficient when heart rates are normal or rapid and when rhythms are regular. If rhythm is irregular, then count for one full minute.
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:
ANS: recognize that a tripod position is often used when a patient is having respiratory difficulties. Assuming a tripod position—leaning forward with arms braced on chair arms—occurs with chronic pulmonary disease. The other actions or assumptions are not correct.
The nurse is assessing a patient's pain. The nurse knows that the most reliable indicator of pain would be the:
ANS: subjective report. The subjective report is the most reliable indicator of pain. Physical examination findings can lend support, but the clinician cannot base the diagnosis of pain exclusively on physical assessment findings.
When measuring a patient's body temperature, the nurse keeps in mind that body temperature is influenced by:
ANS: the diurnal cycle. Normal temperature is influenced by the diurnal cycle, exercise, and age. The other responses do not influence body temperature.
A 60-year-old woman has developed reflexive sympathetic dystrophy after arthroscopic repair of her shoulder. A key feature of this condition is that:
ANS: the slightest touch, such as a sleeve brushing against her arm, causes severe, intense pain. 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.
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:
ANS: unexplained weight loss often accompanies short-term illnesses. 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.
The nurse is unable to palpate the right radial pulse on a patient. The best action would be to:
ANS: use a Doppler device to check for pulsations over the area. 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.
To accurately assess a rectal temperature on an adult, the nurse would:
ANS: use a lubricated blunt tip thermometer. Insert a lubricated rectal thermometer (with a short, blunt tip) only 2 to 3 cm (1 inch) into the adult rectum, and leave in place for 2 1/2 minutes. Cigarette smoking does not alter rectal temperatures.
The most important step that the nurse can take to prevent transmission of microorganisms in the hospital setting is to:
ANS: wash hands before and after contact with each patient. 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.
Optimal nutritional status
Achieved when sufficient nutrients are consumed to support day-today body needs and any increased metabolic demands due to growth, pregnancy, or illness.
Food diaries
Ask individual or fan member to write down everything consumed for a certain period of time. 3 days- 2 weekdays and 1 weekend. Sources of error: 1. Noncompliance 2. Inaccurate recording 3. Atypical intake on recording days 4. Conscious alteration of diet during recording period
Waist-to-Hip Ratio
Assesses body fat distribution. Obese people with more fat in upper body: android obesity (more in abdomen). People with fat in hips and thighs have gynoid obesity. Waist-to-hip ratio: waist circumference/ hip circumference. Greater than 1.0 in men or .8 is android obesity.
Over-nutrition
Caused by the consumption of nutrients- especially calories, sodium, and fat- in excess of body needs. Can lead to obesity, heart disease, diabetes. 17% of children are overweight; and 66% of adults are overweight or obese.
Food Frequency Questionnaire
Counter some of difficulties inherent in 24-hour recall method. Information is collected on how many times the individual eats particular foods, providing estimate of usual intake. Sources of error: 1. Does not always quantify amount of intake 2. Relies on memory for how often a food is eaten
24-hour recall
Easiest and most popular method for obtaining info about dietary intake Sources of error: 1. individual may not be able to recall the type or amount of food eaten. 2. Intake within the last 24 hours may be atypical of usual intake 3. Individual may alter the truth for a variety of reasons 4. Snack items may be underreported
Skinfold Thickness
Estimate body fat stores or extent of obesity or undernutrition. Triceps skin fold (TSF)- most easily accessible. Would measure with calipers. 10% above or above- undernutrition and over nutrition
Mid-upper arm muscle circumference (MAMC)
Estimates skeletal muscle reserves or the amount of lean body mass and is derived from the TSF and the MAC measures.
Anthropometric Measures
Evaluate growth, development, and body composition. Most common are height, weight, triceps skin fold thickness, elbow breadth, and arm and head circumferences.
Cholesterol
Evaluates fat metabolism and risk for cardiovascular disease. 120-200 mg/DL. LDLs- bad cholesterol. HDL- good cholesterol. Coronary artery disease increases as serum cholesterol rises.
Mid-arm muscle area (MAMA)
Good indicator of lean body mass and thus skeletal protein reserves.
Comprehensive Nutritional Assessment
Individuals identified at nutritional risk during screening; includes dietary history and clinical information, physical examination for clinical signs, anthropometric measures, and laboratory tests Used Subjective Global Assessment form for compiling comprehensive nutritional assessment data
C-reactive protein
Inflammatory status produced by liver, used to monitor metabolic stress. Determine when to begin nutritional support in critically ill patients.
Mid-Upper Arm Circumference
MAC estimates skeletal muscle mass and fat stores. Difficult to obtain in older adults because of sagging skin, changes in fat distribution, and declining muscle mass.
Hematocrit
Measure of cell volume, also indicates iron status.
Glucose
Normal for young children (0-2 yr) is 60-110 mg/dL Children: 60-100 mg/DL Adults: <100 mg/DL. Prediabetes: 110-125 mg/dL.
Undernutrition
Nutritional reserves are depleted and/or when nutrient intake is inadequate to meet day-to-day needs or added metabolic demands
Types of malnutrition
Obesity, marasmus (protein-calorie malnutrition), kwashiorkor (protein malnutrition), marasmus-kwashiorkormix
Body weight as a percentage of ideal body weight
Percent ideal body weight = current weight/ ideal weight x 100. Current weight of 80-90% of ideal weight suggests mild malnutrition, <70% severe
Percent usual body weight
Percent usual body weight = current weight/ usual weight x 100. Recent weight change = usual weight- current weight/ usual weight x 100
Elderly and Nutrition
Poor dentition, decreased visual acuity, decreased saliva production, slowed gastrointestinal motility, decreased gastrointestinal absorption, diminished olfactory and taste sensitivity. Decrease in energy requirements due to loss of lean body mass and increase in fat mass.
Body Mass Index (BMI)
Practical marker of optimal weight for height- indicator of obesity or undernutrition. BMI = weight/ height <18.5 = underweight. 18.5-24.9 = normal 25-29.9 = overweight 30-39.9 = obesity Children: <5th percentile- underweight. 5-85th percentile- healthy 85-95th percentile- overweight >95th- obese
Serum proteins
Serum albumin- visceral protein status. Low levels occur with protein-calorie malnutrition, altered hydration, and decreased liver function. Serum transferrin- iron-transport protein. More sensitive.
Cultural stereotyping
Tendency to view individuals of common cultural backgrounds similarly and according to a preconceived notion of how they "ought" to behave.
Prealbumin
Transport protein for thyroxine and retinol-binding protein.
Hemoglobin
Used to detect iron deficiency anemia. Increased levels- hemoconcentration due to polycythemia vera or dehydration. Decreased: anemia, recent hemorrhage.
Triglycerides
Used to screen for hyperlipidemia and risk for coronary artery disease.
Obesity
due to caloric excess to weight more than 20% above ideal body weight or body mass index of 30.0-39.9.
