Chapter 09: General Survey, Measurement, Vital Signs complete solution

Chapter 09: General Survey, Measurement, Vital Signs 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 pressured. Observing specific body systems while performing the physical assessment ans: A: Observing the patient's body stature and nutritional status When measuring a patient's 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: Attempts should be made to weigh the patient at approximately the same time of day, if a sequence of weights is necessary. A patient's 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: Prehypertension 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. ans: A: General health 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. ans: B: Consider these findings normal for a 1-month-old infant. 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: Presence of kyphosis and flexion in the knees and hips 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: Comatose adult 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 infant's 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: Measuring the chest circumference at the nipple line with a tape measure 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: Rapid measurement is useful for uncooperative younger children. 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: Widened pulse pressure 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: Radiation 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. Diurnal cycle. d. Nocturnal cycle. ans: C: .Diurnal cycle When evaluating the temperature of older adults, the nurse should remember which aspect about an older adult's body temperature? a. The body temperature of the older adult is lower than that of a younger adult. b. An older adult's 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: The body temperature of the older adult is lower than that of a younger adult. 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: Unexplained weight loss often accompanies short-term illnesses. 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: Recognize that a tripod position is often used when a patient is having respiratory difficulties. 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 a febrile. 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: Leave the thermometer in place 3 to 4 minutes if the patient is afebrile 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 risk of cross contamination is reduced, compared with the rectal route. 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: Use a lubricated blunt tip thermometer. 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: 1 minute, if the rhythm is irregular. 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 ans: A: Force 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: a. Immediately notify the physician. b. Consider this finding normal in children and young adults. c. Check the child's blood pressure, and note any variation with respiration. d. Document that this child has bradycardia, and continue with the assessment. ans: B: Consider this finding normal in children and young adults. 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 heart's stroke volume. d. Reflects the blood volume in the arteries during diastole. ans: C: Is a reflection of the heart's stroke volume The nurse is assessing the vital signs of a 20-year-old male marathon runner and documents the following vital signs: temperature-36° C; pulse-48 beats per minute; respirations-14 breaths per minute; blood pressure-104/68 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 patient's pulse rate is not normal—his physician should be notified. d. On the basis of these readings, the patient should return to the clinic in 1 week. ans: B: These are normal vital signs for a healthy, athletic adult. 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. Respirations should be counted for 1 full minute, noticing rate and rhythm. b. Child's pulse and respirations should be simultaneously checked for 30 seconds. c. Child's respirations should be checked for a minimum of 5 minutes to identify any variations in his orher respiratory pattern. d. Patient's respirations should be counted for 15 seconds and then multiplied by 4 to obtain the number of respirations per minute. ans: A: Respirations should be counted for 1 full minute, noticing rate and rhythm. A patient's blood pressure is 118/82 mm Hg. He asks the nurse, "What do the numbers mean?" The nurse's 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 top number is the systolic blood pressure and reflects the pressure of the blood against the arteries when the heart contracts." While measuring a patient's 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: Peripheral vascular resistance 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 teenager's blood pressure reading will be lower than that of an adult. ans: B: The blood pressure of a Black adult is usually higher than that of a White adult of the same age. 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: Yield a falsely high blood pressure 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: Allow 5 minutes for him to relax and rest before checking his vital signs. 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: Detect the presence of an auscultatory gap. 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 patient's arm and inflated 30 mm Hg above the patient's 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 patient's p