NUR 216 EXAM 4
NUR 216 health assessment EXAM 4 |
COMPLETE VERIFIED QUESTIONS &
ANSWERS GRADED A+ GUARANTEED
PASS (100% VERIFIED SOLUTIONS)
2025/2026 UPDATED VERSION
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 previous blood pressure readings, the cuff should be inflated
30 mm Hg above the highest systolic reading recorded. - Answer ✓✓C
An auscultatory gap occurs in approximately 5% of the people, most often in those with
hypertension. To check for the presence of an auscultatory gap, the cuff should be inflated 20
to 30 mm Hg beyond the point at which the palpated pulse disappears.
What is pulse pressure? - Answer ✓✓Pulse pressure is the difference between systolic and
diastolic blood pressure (170 - 100 = 70) and reflects the stroke volume.
A+ 1
, NUR 216 EXAM 4
The nurse is helping another nurse to take a blood pressure reading on a patient's thigh.
Which action is correct regarding thigh pressure?
a. Either the popliteal or femoral vessels should be auscultated to obtain a thigh pressure.
b. The best position to measure thigh pressure is the supine position with the knee slightly
bent.
c. If the blood pressure in the arm is high in an adolescent, then it should be
compared with the thigh pressure.
d. The thigh pressure is lower than the pressure in the arm, which is attributable to the
distance away from the heart and the size of the popliteal vessels. - Answer ✓✓C
. A 4-month-old child is at the clinic for a well-baby check-up and immunizations. Which of
these actions is most appropriate when the nurse is assessing an infant's vital signs?
a. The infant's radial pulse should be palpated, and the nurse should notice any fluctuations
resulting from activity or exercise.
b. The nurse should auscultate an apical rate for 1 minute and then assess for any normal
irregularities, such as sinus arrhythmia.
c. The infant's blood pressure should be assessed by using a stethoscope with a large
diaphragm piece to hear the soft muffled Korotkoff sounds.
d. The infant's chest should be observed and the respiratory rate counted for 1 minute; the
respiratory pattern may vary significantly - Answer ✓✓B
The nurse palpates or auscultates an apical rate with infants and toddlers. The pulse should
be counted for 1 full minute to account for normal irregularities, such as sinus arrhythmia.
Children younger than 3 years of age have such small arm vessels; consequently, hearing
Korotkoff sounds with a stethoscope is difficult. The nurse should use either an electronic
blood pressure device that uses oscillometry or a Doppler ultrasound device to amplify the
sounds.
A+ 2
, NUR 216 EXAM 4
The nurse is assessing an 8-year-old child whose growth rate measures below the third
percentile for a child his age. He appears significantly younger than his stated age and is
chubby with infantile facial features. Which condition does this child have?
a. Hypopituitary dwarfism
b. Achondroplastic dwarfism
c. Marfan syndrome
d. Acromegaly - Answer ✓✓A
Hypopituitary dwarfism is caused by a deficiency in growth hormone in childhood and results
in a 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;
the nurse is counting an infant's respirations. Which technique is correct?
a. Watching the chest rise and fall
b. Watching the abdomen for movement
c. Placing a hand across the infant's chest
d. Using a stethoscope to listen to the breath sounds - Answer ✓✓B
infant's respirations are normally more diaphragmatic than thoracic.
When checking for proper blood pressure cuff size, which guideline is correct?
a. The standard cuff size is appropriate for all sizes.
b. The length of the rubber bladder should equal 80% of the arm circumference.
c. The width of the rubber bladder should equal 80% of the arm circumference.
d. The width of the rubber bladder should equal 40% of the arm circumference. - Answer
✓✓D
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.
A+ 3
, NUR 216 EXAM 4
A patient is brought by ambulance to the emergency department with multiple traumas
received in an automobile accident. He is alert and cooperative, but his injuries are quite
severe. How would the nurse proceed with data collection?
a. Collect history information first, then perform the physical examination and institute life-
saving measures.
b. Simultaneously ask history questions while performing the examination and initiating life-
saving measures.
c. Collect all information on the history form, including social support patterns, strengths, and
coping patterns.
d. Perform life-saving measures and delay asking any history questions until the patient is
transferred to the intensive care unit. - Answer ✓✓B
The nurse has implemented several planned interventions to address the nursing diagnosis of
acute pain. Which would be the next appropriate action?
a. Establish priorities.
b. Identify expected outcomes.
c. Evaluate the individual's condition, and compare actual outcomes with expected outcomes.
d. Interpret data, and then identify clusters of cues and make inferences. - Answer ✓✓D
Match the following to what nursing stage they describe:
a. Has little experience with a specified population and uses rules to guide performance.
b. Has an intuitive grasp of a clinical situation and quickly identifies the accurate solution.
c. Sees actions in the context of daily plans for patients.
d. Understands a patient situation as a whole rather than a list of tasks and recognizes the
long-term goals for the patient. - Answer ✓✓A. Novice
B. Expert
A+ 4
NUR 216 health assessment EXAM 4 |
COMPLETE VERIFIED QUESTIONS &
ANSWERS GRADED A+ GUARANTEED
PASS (100% VERIFIED SOLUTIONS)
2025/2026 UPDATED VERSION
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 previous blood pressure readings, the cuff should be inflated
30 mm Hg above the highest systolic reading recorded. - Answer ✓✓C
An auscultatory gap occurs in approximately 5% of the people, most often in those with
hypertension. To check for the presence of an auscultatory gap, the cuff should be inflated 20
to 30 mm Hg beyond the point at which the palpated pulse disappears.
What is pulse pressure? - Answer ✓✓Pulse pressure is the difference between systolic and
diastolic blood pressure (170 - 100 = 70) and reflects the stroke volume.
A+ 1
, NUR 216 EXAM 4
The nurse is helping another nurse to take a blood pressure reading on a patient's thigh.
Which action is correct regarding thigh pressure?
a. Either the popliteal or femoral vessels should be auscultated to obtain a thigh pressure.
b. The best position to measure thigh pressure is the supine position with the knee slightly
bent.
c. If the blood pressure in the arm is high in an adolescent, then it should be
compared with the thigh pressure.
d. The thigh pressure is lower than the pressure in the arm, which is attributable to the
distance away from the heart and the size of the popliteal vessels. - Answer ✓✓C
. A 4-month-old child is at the clinic for a well-baby check-up and immunizations. Which of
these actions is most appropriate when the nurse is assessing an infant's vital signs?
a. The infant's radial pulse should be palpated, and the nurse should notice any fluctuations
resulting from activity or exercise.
b. The nurse should auscultate an apical rate for 1 minute and then assess for any normal
irregularities, such as sinus arrhythmia.
c. The infant's blood pressure should be assessed by using a stethoscope with a large
diaphragm piece to hear the soft muffled Korotkoff sounds.
d. The infant's chest should be observed and the respiratory rate counted for 1 minute; the
respiratory pattern may vary significantly - Answer ✓✓B
The nurse palpates or auscultates an apical rate with infants and toddlers. The pulse should
be counted for 1 full minute to account for normal irregularities, such as sinus arrhythmia.
Children younger than 3 years of age have such small arm vessels; consequently, hearing
Korotkoff sounds with a stethoscope is difficult. The nurse should use either an electronic
blood pressure device that uses oscillometry or a Doppler ultrasound device to amplify the
sounds.
A+ 2
, NUR 216 EXAM 4
The nurse is assessing an 8-year-old child whose growth rate measures below the third
percentile for a child his age. He appears significantly younger than his stated age and is
chubby with infantile facial features. Which condition does this child have?
a. Hypopituitary dwarfism
b. Achondroplastic dwarfism
c. Marfan syndrome
d. Acromegaly - Answer ✓✓A
Hypopituitary dwarfism is caused by a deficiency in growth hormone in childhood and results
in a 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;
the nurse is counting an infant's respirations. Which technique is correct?
a. Watching the chest rise and fall
b. Watching the abdomen for movement
c. Placing a hand across the infant's chest
d. Using a stethoscope to listen to the breath sounds - Answer ✓✓B
infant's respirations are normally more diaphragmatic than thoracic.
When checking for proper blood pressure cuff size, which guideline is correct?
a. The standard cuff size is appropriate for all sizes.
b. The length of the rubber bladder should equal 80% of the arm circumference.
c. The width of the rubber bladder should equal 80% of the arm circumference.
d. The width of the rubber bladder should equal 40% of the arm circumference. - Answer
✓✓D
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.
A+ 3
, NUR 216 EXAM 4
A patient is brought by ambulance to the emergency department with multiple traumas
received in an automobile accident. He is alert and cooperative, but his injuries are quite
severe. How would the nurse proceed with data collection?
a. Collect history information first, then perform the physical examination and institute life-
saving measures.
b. Simultaneously ask history questions while performing the examination and initiating life-
saving measures.
c. Collect all information on the history form, including social support patterns, strengths, and
coping patterns.
d. Perform life-saving measures and delay asking any history questions until the patient is
transferred to the intensive care unit. - Answer ✓✓B
The nurse has implemented several planned interventions to address the nursing diagnosis of
acute pain. Which would be the next appropriate action?
a. Establish priorities.
b. Identify expected outcomes.
c. Evaluate the individual's condition, and compare actual outcomes with expected outcomes.
d. Interpret data, and then identify clusters of cues and make inferences. - Answer ✓✓D
Match the following to what nursing stage they describe:
a. Has little experience with a specified population and uses rules to guide performance.
b. Has an intuitive grasp of a clinical situation and quickly identifies the accurate solution.
c. Sees actions in the context of daily plans for patients.
d. Understands a patient situation as a whole rather than a list of tasks and recognizes the
long-term goals for the patient. - Answer ✓✓A. Novice
B. Expert
A+ 4
