NUR 210 EXAM 1 GALEN COLLEGE OF NURSING LATEST
ACTUAL EXAM
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 -
ANSWER: A
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. - ANSWER: D
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?
A) Normal blood pressure
B) Prehypertension
C) Stage I hypertension
D) Stage 2 hypertension - ANSWER: B
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. - ANSWER: A
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:
A) refer the infant to a physician for further evaluation.
B) consider this a normal finding 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. - ANSWER: A
The nurse is assessing an 80-year-old male patient. Which assessment findings would
be
considered normal?
A) An increase in body weight from younger years
B) Additional deposits of fat on the thighs and lower legs
C) The presence of kyphosis and flexion in the knees and hips
D) A change in overall body proportion, a longer trunk, and shorter extremities -
ANSWER: 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 - ANSWER: 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 - ANSWER: C
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. -
ANSWER: A
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 - ANSWER: 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 - ANSWER: B
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 - ANSWER: C
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 - ANSWER: A
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) his weight loss is probably from unhealthy eating habits.
B) chronic diseases such as hypertension cause weight loss.
C) unexplained weight loss often accompanies short-term illnesses.
D) his weight loss is probably the result of a mental health dysfunction. - ANSWER: C
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. - ANSWER: D
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. - ANSWER: B
, 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. - ANSWER: C
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. - ANSWER: 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. - ANSWER: 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 - ANSWER: A
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) notify the physician immediately.
B) consider this a normal finding 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. -
ANSWER: B
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. - ANSWER: C
ACTUAL EXAM
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 -
ANSWER: A
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. - ANSWER: D
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?
A) Normal blood pressure
B) Prehypertension
C) Stage I hypertension
D) Stage 2 hypertension - ANSWER: B
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. - ANSWER: A
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:
A) refer the infant to a physician for further evaluation.
B) consider this a normal finding 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. - ANSWER: A
The nurse is assessing an 80-year-old male patient. Which assessment findings would
be
considered normal?
A) An increase in body weight from younger years
B) Additional deposits of fat on the thighs and lower legs
C) The presence of kyphosis and flexion in the knees and hips
D) A change in overall body proportion, a longer trunk, and shorter extremities -
ANSWER: 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 - ANSWER: 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 - ANSWER: C
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. -
ANSWER: A
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 - ANSWER: 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 - ANSWER: B
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 - ANSWER: C
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 - ANSWER: A
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) his weight loss is probably from unhealthy eating habits.
B) chronic diseases such as hypertension cause weight loss.
C) unexplained weight loss often accompanies short-term illnesses.
D) his weight loss is probably the result of a mental health dysfunction. - ANSWER: C
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. - ANSWER: D
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. - ANSWER: B
, 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. - ANSWER: C
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. - ANSWER: 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. - ANSWER: 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 - ANSWER: A
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) notify the physician immediately.
B) consider this a normal finding 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. -
ANSWER: B
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. - ANSWER: C
