NURS 261 Mid-Term Exam Study Guide
2025-2026 | Health Assessment for Nursing
Practice(Questions &Verified Answers)
1.The nurse assesses the following vital signs of a 78-year-old male,
temperature at 36.6°C, temporal, 72 bpm regular 2+, respirations 18
breaths per minute, regular no use of accessory muscles, blood
pressure 142/92 mm HG, which of the findings is
abnormal?..ANSWER..Blood pressure
In older adults, both SBP and DBP increase due to increase stiffness of
arterial walls. The blood pressure finding number was outside of
normal range.
2.The best way to assess a client respiratory rate is
by?..ANSWER..Observing and counting respirations for 30 seconds and
multiplying by two without mentioning that you were observing the
respirations
3.The patient's radial pulse is weak and threaded. The next action for
the nurse is to?..ANSWER..Compare findings with previous findings
and opposite extremity
4.which of the of the patients should not have a temperature measured
orally?
A female with diarrhea.
B. 30 year old patient with an earache
C. 45 year old man with chest pain
D. 62-year-old female who has had oral surgery..ANSWER..D
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,Oral temperature measurement is contraindicated in a patient who
has altered mental status, is a mouth breather, recent oral intake, or
have smoked, or undergone oral surgery
5.The nurse notes iregular radial pulse in a patient. Further evaluation
includes assessing what?..ANSWER..for a pulse deficit
6.which actions were result in an inaccurate BP reading? Select all that
apply.
A. BP reading immediately after the patient has entered the room
B. Using BP cuff with a bladder that is a 80 percent of the arm
circumference
C. Asking the patient to hold up their arm above heart level
D. pumping the cuff 10 mm HG above the palpated SBP..ANSWER..A, C,
D.
7.Adult patients may have variations in pulse rates with
A. respirations.
B. food intake.
C. heat.
D. exercise...ANSWER..exercise
8.an unconscious 20-year-old male arrives at the hospital after
experimenting with hallucinogenic substances. His vital signs are
temperature 37.2°C, 142 bpm, respirations 20 breast per minute, blood
pressure 100/64 The patient is experiencing
what?..ANSWER..tachycardia
Heart rate greater than 100 bpm in an adult
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,9.An auscultatory gap is defined as..
A. a drop in the SBP of 15 mm Hg or more with position change
B. A period of silence heard between Korotkoff sounds
C. the difference between the apical and radial pulse
D. SBP minus the DBP..ANSWER..B. A period of silence heard between
Korotkoff sounds
common in older adults and those with chronic disease
10.Which of the following findings general assessment indicate a
change status? Select a letter apply.
A. Disheveled appearance.
B. Rapid speech.
c. Lethargy.
D. Asymmetrical movements...ANSWER..A, B, C
11.The patient has a pain of a short duration with an identifiable cause.
This is referred to as?
A. Acute pain.
B. Chronic pain.
C. Neuropathic pain.
D. Complex pain...ANSWER..A.
Acute pain is a short duration, chronic pain less more than 3 to 6
months
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, 11.to identify the location of pain, the nurse asked the patient?
A. How long they've had the pain.
B. To write the intention of the pain on a scale from 0 to 10.
C. To point to the painful area.
D. Describe the quality of pain...ANSWER..C.
12.A patient says that their pain worsen with weight-bearing activity.
The nurse will consider this?
A. And alleviating factor.
B. A functional pain goal.
C. A quality description.
D. An aggravating factor...ANSWER..D.
13.which of the following tools would a nurse used to perform a
multidimensional pain assessment?
A. Visual analog scale.
B. Brief pain Inventory.
C. Numeric pain and intensity.
D. Verbal descriptor...ANSWER..B
The BPI includes a pain, attention scale, a body diagram to locate the
pain, a functional assessment, and questions about efficiency of pain
medication's . Making it multidimensional.
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2025-2026 | Health Assessment for Nursing
Practice(Questions &Verified Answers)
1.The nurse assesses the following vital signs of a 78-year-old male,
temperature at 36.6°C, temporal, 72 bpm regular 2+, respirations 18
breaths per minute, regular no use of accessory muscles, blood
pressure 142/92 mm HG, which of the findings is
abnormal?..ANSWER..Blood pressure
In older adults, both SBP and DBP increase due to increase stiffness of
arterial walls. The blood pressure finding number was outside of
normal range.
2.The best way to assess a client respiratory rate is
by?..ANSWER..Observing and counting respirations for 30 seconds and
multiplying by two without mentioning that you were observing the
respirations
3.The patient's radial pulse is weak and threaded. The next action for
the nurse is to?..ANSWER..Compare findings with previous findings
and opposite extremity
4.which of the of the patients should not have a temperature measured
orally?
A female with diarrhea.
B. 30 year old patient with an earache
C. 45 year old man with chest pain
D. 62-year-old female who has had oral surgery..ANSWER..D
1|Page
,Oral temperature measurement is contraindicated in a patient who
has altered mental status, is a mouth breather, recent oral intake, or
have smoked, or undergone oral surgery
5.The nurse notes iregular radial pulse in a patient. Further evaluation
includes assessing what?..ANSWER..for a pulse deficit
6.which actions were result in an inaccurate BP reading? Select all that
apply.
A. BP reading immediately after the patient has entered the room
B. Using BP cuff with a bladder that is a 80 percent of the arm
circumference
C. Asking the patient to hold up their arm above heart level
D. pumping the cuff 10 mm HG above the palpated SBP..ANSWER..A, C,
D.
7.Adult patients may have variations in pulse rates with
A. respirations.
B. food intake.
C. heat.
D. exercise...ANSWER..exercise
8.an unconscious 20-year-old male arrives at the hospital after
experimenting with hallucinogenic substances. His vital signs are
temperature 37.2°C, 142 bpm, respirations 20 breast per minute, blood
pressure 100/64 The patient is experiencing
what?..ANSWER..tachycardia
Heart rate greater than 100 bpm in an adult
2|Page
,9.An auscultatory gap is defined as..
A. a drop in the SBP of 15 mm Hg or more with position change
B. A period of silence heard between Korotkoff sounds
C. the difference between the apical and radial pulse
D. SBP minus the DBP..ANSWER..B. A period of silence heard between
Korotkoff sounds
common in older adults and those with chronic disease
10.Which of the following findings general assessment indicate a
change status? Select a letter apply.
A. Disheveled appearance.
B. Rapid speech.
c. Lethargy.
D. Asymmetrical movements...ANSWER..A, B, C
11.The patient has a pain of a short duration with an identifiable cause.
This is referred to as?
A. Acute pain.
B. Chronic pain.
C. Neuropathic pain.
D. Complex pain...ANSWER..A.
Acute pain is a short duration, chronic pain less more than 3 to 6
months
3|Page
, 11.to identify the location of pain, the nurse asked the patient?
A. How long they've had the pain.
B. To write the intention of the pain on a scale from 0 to 10.
C. To point to the painful area.
D. Describe the quality of pain...ANSWER..C.
12.A patient says that their pain worsen with weight-bearing activity.
The nurse will consider this?
A. And alleviating factor.
B. A functional pain goal.
C. A quality description.
D. An aggravating factor...ANSWER..D.
13.which of the following tools would a nurse used to perform a
multidimensional pain assessment?
A. Visual analog scale.
B. Brief pain Inventory.
C. Numeric pain and intensity.
D. Verbal descriptor...ANSWER..B
The BPI includes a pain, attention scale, a body diagram to locate the
pain, a functional assessment, and questions about efficiency of pain
medication's . Making it multidimensional.
4|Page
