NUR2459 / NUR 2459 Final Exam 2023/2024 (2 NEW VERSIONS) Mental & Behavioral Health Nursing - Questions and Answers.

NUR2459 / NUR 2459 Final Exam 2023/2024 (2 NEW VERSIONS) Mental & Behavioral Health Nursing - Questions and Answers. 1. The nurse is performing a general survey. Which action is a component of the general survey? Observing the patient’s body stature and nutritional status 2. When measuring a patient’s weight, the nurse is aware of which of these guidelines? Attempts should be made to weigh the patient at approximately the same time of day, if a sequence of weights is necessary. 3. 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? Prehypertension 4. During an examination of a child, the nurse considers that physical growth is the best index of a child’s: General health. 5. A 1-month-old infant has a head measurement of 34 cm and has a chest circumference of 32 cm. Based on the interpretation of these findings, the nurse would: Consider these findings normal for a 1-month-old infant. 6. The nurse is assessing an 80-year-old male patient. Which assessment findings would be considered normal? Presence of kyphosis and flexion in the knees and hips 7. The nurse should measure rectal temperatures in which of these patients? Comatose adult 8. The nurse is preparing to measure the length, weight, chest, and head circumference of a 6-month-old infant. Which measurement technique is correct? Measuring the chest circumference at the nipple line with a tape measure NUR2459 / NUR 2459 Final Exam 2023/2024 (2 NEW VERSIONS) Mental & Behavioral Health Nursing - Questions and Answers. NUR2459 / NUR 2459: Final Exam (Latest 2023/ 2024) Mental & Behavioral Health Nursing Distribution of this document is illegal 9. The nurse knows that one advantage of the tympanic membrane thermometer (TMT) is that: Rapid measurement is useful for uncooperative younger children. 10. When assessing an older adult, which vital sign changes occur with aging? Widened pulse pressure 11. The nurse is examining a patient who is complaining of feeling cold. Which is a mechanism of heat loss in the body? Radiation 12. When measuring a patients body temperature, the nurse keeps in mind that body temperature is influenced by: Diurnal cycle. 13. When evaluating the temperature of older adults, the nurse should remember which aspect about an older adult’s body temperature The body temperature of the older adult is lower than that of a younger adult. 14. A 60-year-old male patient has been treated for pneumonia for the past 6 weeks. He is seen today in the clinic for an unexplained weight loss of 10 pounds over the last 6 weeks. The nurse knows that: Unexplained weight loss often accompanies short-term illnesses. 15. When assessing a 75-year-old patient who has asthma, the nurse notes that he assumes a tripod position, leaning forward with arms braced on the chair. On the basis of this observation, the nurse should: d. 16. Which of these actions illustrates the correct technique the nurse should use when assessing oral temperature with a mercury thermometer? b. Leave the thermometer in place 3 to 4 minutes if the patient is afebrile. 17. The nurse is taking temperatures in a clinic with a TMT. Which statement is true regarding use of the TMT? Recognize that a tripod position is often used when a patient is having respiratory difficulties. NUR2459 / NUR 2459: Final Exam (Latest 2023/ 2024) Mental & Behavioral Health Nursing Distribution of this document is illegal c. 18. To assess a rectal temperature accurately in an adult, the nurse would: a. Use a lubricated blunt tip thermometer. 19. Which technique is correct when the nurse is assessing the radial pulse of a patient? The pulse is counted for: a. 1 minute, if the rhythm is irregular. 20. When assessing a patient’s pulse, the nurse should also notice which of these characteristics? Force 21. When assessing the pulse of a 6-year-old boy, the nurse notices that his heart rate varies with his respiratory cycle, speeding up at the peak of inspiration and slowing to normal with expiration. The nurses next action would be to: b. Consider this finding normal in children and young adults. 22. When assessing the force, or strength, of a pulse, the nurse recalls that the pulse: c. Is a reflection of the hearts stroke volume. 23. The nurse is assessing the vital signs of a 20-year-old male marathon runner and documents the following vital signs: temperature36 C; pulse48 beats per minute; respirations14 breaths per minute; blood pressure104/68 mm Hg. Which statement is true concerning these results? b. These are normal vital signs for a healthy, athletic adult. 24. The nurse is assessing the vital signs of a 3-year-old patient who appears to have an irregular respiratory pattern. How should the nurse assess this child’s respirations? a. 25. A patient’s blood pressure The risk of cross-contamination is reduced, compared with the rectal route. Respirations should be counted for 1 full minute, noticing rate and rhythm. NUR2459 / NUR 2459: Final Exam (Latest 2023/ 2024) Mental & Behavioral Health Nursing Distribution of this document is illegal is 118/82 mm Hg. He asks the nurse, what do the numbers mean? The nurses best reply is: c. 26. While measuring a patient’s blood pressure, the nurse recalls that certain factors, such as , help determine blood pressure. d. Peripheral vascular resistance 27. A nurse is helping at a health fair at a local mall. When taking blood pressures on a variety of people, the nurse keeps in mind that: b. 28. The nurse notices a colleague is preparing to check the blood pressure of a patient who is obese by using a standard-sized blood pressure cuff. The nurse should expect the reading to: b. Yield a falsely high blood pressure. 29. A student is late for his appointment and has rushed across campus to the health clinic. The nurse should: a. 30. The nurse will perform a palpated pressure before auscultating blood pressure. The reason for this is to: b. Detect the presence of an auscultatory gap. 31. The nurse is taking an initial blood pressure reading on a 72-year-old patient with documented hypertension. How should the nurse proceed? c. The top number is the systolic blood pressure and reflects the pressure of the blood against the arteries when the heart contracts . The blood pressure of a Black adult is usually higher than that of a White adult of the same age. Allow 5 minutes for him to relax and rest before checking his vital signs. Cuff should be inflated 30 mm Hg above the point at which the palpated pulse disappears. NUR2459 / NUR 2459: Final Exam (Latest 2023/ 2024) Mental & Behavioral Health Nursing Distribution of this document is illegal 32. The nurse has collected the following information on a patient: palpated blood pressure180 mm Hg; auscultated blood pressure170/100 mm Hg; apical pulse60 beats per minute; radial pulse70 beats per minute. What is the patients pulse pressure? b. 70 33. When auscultating the blood pressure of a 25-year-old patient, the nurse notices the phase I Korotkoff sounds begin at 200 mm Hg. At 100 mm Hg, the Korotkoff sounds muffle. At 92 mm Hg, the Korotkoff sounds disappear. How should the nurse record this patient’s blood pressure? a. 200/92 34. A patient is seen in the clinic for complaints of fainting episodes that started last week. How should the nurse proceed with the examination? c. 35. A 70-year-old man has a blood pressure of 150/90 mm Hg in a lying position, 130/80 mm Hg in a sitting position, and 100/60 mm Hg in a standing position. How should the nurse evaluate these findings? b. The change in blood pressure readings is called orthostatic hypotension.