Nursing 2058 Health Assessment Exam 2:Study Guide Questions with Answers 2024-2025, Exams of Nursing

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Nursing 2058 Health Assessment

Exam 2: Study Guide Questions

with Answers

Chapter 08:

1. When performing a physical assessment, the first technique the nurse will always use is: a. Palpation. b. Inspection. c. Percussion. d. Auscultation. B The skills requisite for the physical examination are inspection, palpation, percussion, and auscultation. The skills are performed one at a time and in this order (with the exception of the abdominal assessment, during which auscultation takes place before palpation and percussion). The assessment of each body system begins with inspection. A focused inspection takes time and yields a surprising amount of information.
2. The nurse is preparing to perform a physical assessment. Which statement is true about the physical assessment? The inspection phase: a. Usually^ yields^ little^ information. b. Takes time and reveals a surprising amount of information. c. May^ be^ somewhat^ uncomfortable^ for^ the expert practitioner. d. Requires^ a^ quick^ glance^ at^ the patient’s body systems before proceeding with palpation. B A focused inspection takes time and yields a surprising amount of information. Initially, the examiner may feel uncomfortable, staring at the person without also doing something. A focused assessment is significantly more than a “quick glance.”
3. The nurse is assessing a patient’s skin during an office visit. What part of the hand and technique should be used to best assess the patient’s skin temperature? a. Fingertips;^ they^ are^ more^ sensitive^ to small changes in temperature. b. Dorsal surface of the hand; the skin is thinner on this surface than on the palms.

c. Ulnar^ portion^ of^ the^ hand;^ increased^ blood supply in this area enhances temperature sensitivity. d. Palmar^ surface^ of^ the^ hand;^ this^ surface^ is the most sensitive to temperature variations because of its increased nerve supply in this area. B The dorsa (backs) of the hands and fingers are best for determining temperature because the skin is thinner on the dorsal surfaces than on the palms. Fingertips are best for fine, tactile discrimination. The other responses are not useful for palpation.

4. Which of these techniques uses the sense of touch to assess texture, temperature, moisture, and swelling when the nurse is assessing a patient? a. Palpation b. Inspection c. Percussion d. Auscultation A Palpation uses the sense of touch to assess the patient for these factors. Inspection involves vision; percussion assesses through the use of palpable vibrations and audible sounds; and auscultation uses the sense of hearing.
5. The nurse is preparing to assess a patient’s abdomen by palpation. How should the nurse proceed? a. Palpation^ of^ reportedly^ “tender”^ areas^ are avoided because palpation in these areas may cause pain. b. Palpating a tender area is quickly performed to avoid any discomfort that the patient may experience. c. The assessment begins with deep palpation, while encouraging the patient to relax and to take deep breaths. d. The assessment begins with light palpation to detect surface characteristics and to accustom the patient to being touched. D Light palpation is initially performed to detect any surface characteristics and to accustom the person to being touched. Tender areas should be palpated last, not first.
6. The nurse would use bimanual palpation technique in which situation?

a. Palpating the thorax of an infant b. Palpating the kidneys and uterus c. Assessing pulsations and vibrations d. Assessing^ the^ presence^ of^ tenderness^ and pain B Bimanual palpation requires the use of both hands to envelop or capture certain body parts or organs such as the kidneys, uterus, or adnexa. The other situations are not appropriate for bimanual palpation.

7. The nurse is preparing to percuss the abdomen of a patient. The purpose of the percussion is to assess the of the underlying tissue. a. Turgor b. Texture c. Density d. Consistency C Percussion yields a sound that depicts the location, size, and density of the underlying organ. Turgor and texture are assessed with palpation.
8. The nurse is reviewing percussion techniques with a newly graduated nurse. Which technique, if used by the new nurse, indicates that more review is needed? a. Percussing once over each area b. Quickly^ lifting^ the^ striking^ finger^ after each stroke c. Striking^ with^ the^ fingertip,^ not^ the^ finger pad d. Using^ the^ wrist^ to^ make^ the^ strikes,^ not^ the arm A For percussion, the nurse should percuss two times over each location. The striking finger should be quickly lifted because a resting finger damps off vibrations. The tip of the striking finger should make contact, not the pad of the finger. The wrist must be relaxed and is used to make the strikes, not the arm.
9. When percussing over the liver of a patient, the nurse notices a dull sound. The nurse should: a. Consider this a normal finding. b. Palpate this area for an underlying mass.

c. Reposition the hands, and attempt to percuss in this area again. d. Consider this finding as abnormal, and refer the patient for additional treatment. A Percussion over relatively dense organs, such as the liver or spleen, will produce a dull sound. The other responses are not correct.

10. The nurse is unable to identify any changes in sound when percussing over the abdomen of an obese patient. What should the nurse do next? a. Ask^ the^ patient^ to^ take^ deep^ breaths^ to relax the abdominal musculature. b. Consider this finding as normal, and proceed with the abdominal assessment. c. Increase^ the^ amount^ of^ strength^ used^ when attempting to percuss over the abdomen. d. Decrease^ the^ amount^ of^ strength^ used when attempting to percuss over the abdomen. C The thickness of the person’s body wall will be a factor. The nurse needs a stronger percussion stroke for persons with obese or very muscular body walls. The force of the blow determines the loudness of the note. The other actions are not correct.
11. The nurse hears bilateral loud, long, and low tones when percussing over the lungs of a 4 - year-old child. The nurse should: a. Palpate^ over^ the^ area^ for^ increased^ pain and tenderness. b. Ask^ the^ child^ to^ take^ shallow^ breaths,^ and percuss over the area again. c. Immediately^ refer^ the^ child^ because^ of^ an increased amount of air in the lungs. d. Consider^ this^ finding^ as^ normal^ for^ a^ child this age, and proceed with the examination. D Percussion notes that are loud in amplitude, low in pitch, of a booming quality, and long in duration are normal over a child’s lung.
12. A patient has suddenly developed shortness of breath and appears to be in significant

respiratory distress. After calling the physician and placing the patient on oxygen, which of these actions is the best for the nurse to take when further assessing the patient?

a. Count the patient’s respirations. b. Bilaterally^ percuss^ the^ thorax,^ noting^ any differences in percussion tones. c. Call^ for^ a^ chest^ x-ray^ study,^ and^ wait for the results before beginning an assessment. d. Inspect^ the^ thorax^ for^ any^ new^ masses^ and bleeding associated with respirations. B Percussion is always available, portable, and offers instant feedback regarding changes in underlying tissue density, which may yield clues of the patient’s physical status.

13. The nurse is teaching a class on basic assessment skills. Which of these statements is true regarding the stethoscope and its use? a. Slope^ of^ the^ earpieces^ should^ point posteriorly (toward the occiput). b. Although^ the^ stethoscope^ does^ not magnify sound, it does block out extraneous room noise. c. Fit^ and^ quality^ of^ the^ stethoscope^ are^ not as important as its ability to magnify sound. d. Ideal^ tubing^ length^ should^ be^22 inches^ to dampen the distortion of sound. B The stethoscope does not magnify sound, but it does block out extraneous room sounds. The slope of the earpieces should point forward toward the examiner’s nose. Long tubing will distort sound. The fit and quality of the stethoscope are both important. 14. The nurse is preparing to use a stethoscope for auscultation. Which statement is true regarding the diaphragm of the stethoscope? The diaphragm: a. Is used to listen for high-pitched sounds. b. Is used to listen for low-pitched sounds. c. Should be lightly held against the person’s skin to block out low-pitched sounds. d. Should be lightly held against the person’s skin to listen for extra heart sounds and murmurs. A The diaphragm of the stethoscope is best for listening to high-pitched sounds such as

breath, bowel, and normal heart sounds. It should be firmly held against the person’s skin, firmly enough to leave a ring. The bell of the stethoscope is best for soft, low-pitched sounds such as extra heart sounds or murmurs.

15. Before auscultating the abdomen for the presence of bowel sounds on a patient, the nurse should: a. Warm^ the^ endpiece^ of^ the^ stethoscope by placing it in warm water. b. Leave the gown on the patient to ensure that he or she does not get chilled during the examination. c. Ensure^ that^ the^ bell^ side^ of^ the^ stethoscope is turned to the “on” position. d. Check^ the^ temperature^ of^ the^ room,^ and offer blankets to the patient if he or she feels cold. D The examination room should be warm. If the patient shivers, then the involuntary muscle contractions can make it difficult to hear the underlying sounds. The end of the stethoscope should be warmed between the examiner’s hands, not with water. The nurse should never listen through a gown. The diaphragm of the stethoscope should be used to auscultate for bowel sounds.
16. The nurse will use which technique of assessment to determine the presence of crepitus, swelling, and pulsations? a. Palpation b. Inspection c. Percussion d. Auscultation A Palpation applies the sense of touch to assess texture, temperature, moisture, organ location and size, as well as any swelling, vibration or pulsation, rigidity or spasticity, crepitation, presence of lumps or masses, and the presence of tenderness or pain. 17. The nurse is preparing to use an otoscope for an examination. Which statement is true regarding the otoscope? The otoscope: a. Is^ often^ used^ to^ direct^ light^ onto^ the sinuses. b. Uses^ a^ short,^ broad^ speculum^ to^ help visualize the ear. c. Is used to examine the structures of the

internal ear. d. Directs^ light^ into^ the^ ear^ canal^ and^ onto the tympanic membrane. D The otoscope directs light into the ear canal and onto the tympanic membrane that divides the external and middle ear. A short, broad speculum is used to visualize the nares.

18. An examiner is using an ophthalmoscope to examine a patient’s eyes. The patient has astigmatism and is nearsighted. The use of which of these techniques would indicate that the examination is being correctly performed? a. Using^ the^ large^ full^ circle^ of^ light^ when assessing pupils that are not dilated b. Rotating^ the^ lens^ selector^ dial^ to^ the^ black numbers to compensate for astigmatism c. Using the grid on the lens aperture dial to visualize the external structures of the eye d. Rotating^ the^ lens^ selector^ dial^ to^ bring^ the object into focus D The ophthalmoscope is used to examine the internal eye structures. It can compensate for nearsightedness or farsightedness, but it will not correct for astigmatism. The grid is used to assess size and location of lesions on the fundus. The large full spot of light is used to assess dilated pupils. Rotating the lens selector dial brings the object into focus.
19. The nurse is unable to palpate the right radial pulse on a patient. The best action would be to: a. Auscultate over the area with a fetoscope. b. Use^ a^ goniometer^ to^ measure^ the pulsations. c. Use^ a^ Doppler^ device^ to^ check^ for pulsations over the area. d. Check^ for^ the^ presence^ of^ pulsations^ with a stethoscope. C Doppler devices are used to augment pulse or blood pressure measurements. Goniometers measure joint range of motion. A fetoscope is used to auscultate fetal heart tones. Stethoscopes are used to auscultate breath, bowel, and heart sounds.
20. The nurse is preparing to perform a physical assessment. The correct action by the nurse is reflected by which statement? The nurse:

a. Performs^ the^ examination^ from^ the^ left side of the bed. b. Examines^ tender^ or^ painful^ areas^ first^ to help relieve the patient’s anxiety. c. Follows^ the^ same^ examination^ sequence, regardless of the patient’s age or condition. d. Organizes the assessment to ensure that the patient does not change positions too often. D The steps of the assessment should be organized to ensure that the patient does not change positions too often. The sequence of the steps of the assessment may differ, depending on the age of the person and the examiner’s preference. Tender or painful areas should be assessed last.

21. A man is at the clinic for a physical examination. He states that he is “very anxious” about the physical examination. What steps can the nurse take to make him more comfortable? a. Appear^ unhurried^ and^ confident^ when examining him. b. Stay^ in^ the^ room^ when^ he^ undresses^ in case he needs assistance. c. Ask^ him^ to^ change^ into^ an^ examining gown and to take off his undergarments. d. Defer^ measuring^ vital^ signs^ until^ the^ end of the examination, which allows him time to become comfortable. A Anxiety can be reduced by an examiner who is confident, self-assured, considerate, and unhurried. Familiar and relatively nonthreatening actions, such as measuring the person’s vital signs, will gradually accustom the person to the examination.
22. When performing a physical examination, safety must be considered to protect the examiner and the patient against the spread of infection. Which of these statements describes the most appropriate action the nurse should take when performing a physical examination? a. Washing^ one’s^ hands^ after^ removing gloves is not necessary, as long as the gloves are still intact. b. Hands are washed before and after every

physical patient encounter. c. Hands^ are^ washed^ before^ the^ examination of each body system to prevent the spread of bacteria from one part of the body to another. d. Gloves are worn throughout the entire examination to demonstrate to the patient concern regarding the spread of infectious diseases. B The nurse should wash his or her hands before and after every physical patient encounter; after contact with blood, body fluids, secretions, and excretions; after contact with any equipment contaminated with body fluids; and after removing gloves. Hands should be washed after gloves have been removed, even if the gloves appear to be intact. Gloves should be worn when potential contact with any body fluids is present.

23. The nurse is examining a patient’s lower leg and notices a draining ulceration. Which of these actions is most appropriate in this situation? a. Washing^ hands,^ and^ contacting the physician b. Continuing^ to^ examine^ the^ ulceration,^ and then washing hands c. Washing^ hands,^ putting^ on^ gloves, and continuing with the examination of the ulceration d. Washing hands, proceeding with rest of the physical examination, and then continuing with the examination of the leg ulceration C The examiner should wear gloves when the potential contact with any body fluids is present. In this situation, the nurse should wash his or her hands, put on gloves, and continue examining the ulceration.
24. During the examination, offering some brief teaching about the patient’s body or the examiner’s findings is often appropriate. Which one of these statements by the nurse is most appropriate? a. “Your^ atrial^ dysrhythmias^ are under control.” b. “You^ have^ pitting^ edema^ and mild varicosities.”

c. “Your^ pulse^ is^80 beats^ per^ minute, which is within the normal range.” d. “I’m^ using^ my^ stethoscope^ to^ listen^ for any crackles, wheezes, or rubs.” C The sharing of some information builds rapport, as long as the patient is able to understand the terminology.

25. The nurse keeps in mind that the most important reason to share information and to offer brief teaching while performing the physical examination is to help the: a. Examiner^ feel^ more^ comfortable^ and^ to gain control of the situation. b. Examiner^ to^ build^ rapport^ and^ to^ increase the patient’s confidence in him or her. c. Patient^ understand^ his^ or^ her^ disease process and treatment modalities. d. Patient^ identify^ questions^ about^ his^ or^ her disease and the potential areas of patient education. B Sharing information builds rapport and increases the patient’s confidence in the examiner. It also gives the patient a little more control in a situation during which feeling completely helpless is often present.
26. The nurse is examining an infant and prepares to elicit the Moro reflex at which time during the examination? a. When the infant is sleeping b. At the end of the examination c. Before^ auscultation^ of^ the^ thorax d. Halfway through the examination B The Moro or startle reflex is elicited at the end of the examination because it may cause the infant to cry.
27. When preparing to perform a physical examination on an infant, the nurse should: a. Have^ the^ parent^ remove^ all^ clothing except the diaper on a boy. b. Instruct the parent to feed the infant

immediately before the examination. c. Encourage^ the^ infant^ to^ suck^ on^ a^ pacifier during the abdominal examination. d. Ask^ the^ parent^ to^ leave^ the^ room^ briefly when assessing the infant’s vital signs. A The parent should always be present to increase the child’s feeling of security and to understand normal growth and development. The timing of the examination should be 1 to 2 hours after feeding when the baby is neither too drowsy nor too hungry. Infants do not object to being nude; clothing should be removed, but a diaper should be left on a boy.

28. A 6 - month-old infant has been brought to the well-child clinic for a check-up. She is currently sleeping. What should the nurse do first when beginning the examination? a. Auscultate^ the^ lungs^ and^ heart^ while^ the infant is still sleeping. b. Examine^ the^ infant’s^ hips,^ because this procedure is uncomfortable. c. Begin^ with^ the^ assessment^ of^ the^ eye,^ and continue with the remainder of the examination in a head-to-toe approach. d. Wake the infant before beginning any portion of the examination to obtain the most accurate assessment of body systems. A When the infant is quiet or sleeping is an ideal time to assess the cardiac, respiratory, and abdominal systems. Assessment of the eye, ear, nose, and throat are invasive procedures that should be performed at the end of the examination.
29. A 2 - year-old child has been brought to the clinic for a well-child checkup. The best way for the nurse to begin the assessment is to: a. Ask^ the^ parent^ to^ place^ the^ child^ on^ the examining table. b. Have the parent remove all of the child’s clothing before the examination. c. Allow^ the^ child^ to^ keep^ a^ security^ object such as a toy or blanket during the examination. d. Initially focus the interactions on the child, essentially ignoring the parent until

the child’s trust has been obtained. C The best place to examine the toddler is on the parent’s lap. Toddlers understand symbols; therefore, a security object is helpful. Initially, the focus is more on the parent, which allows the child to adjust gradually and to become familiar with you. A 2-year-old child does not like to take off his or her clothes. Therefore, ask the parent to undress one body part at a time.

30. The nurse is examining a 2 - year-old child and asks, “May I listen to your heart now?” Which critique of the nurse’s technique is most accurate? a. Asking^ questions^ enhances^ the child’s autonomy b. Asking^ the^ child^ for^ permission^ helps develop a sense of trust c. This^ question^ is^ an^ appropriate^ statement because children at this age like to have choices d. Children at this age like to say, “No.” The examiner should not offer a choice when no choice is available D Children at this age like to say, “No.” Choices should not be offered when no choice is really available. If the child says, “No” and the nurse does it anyway, then the nurse loses trust. Autonomy is enhanced by offering a limited option, “Shall I listen to your heart next or your tummy?”
31. With which of these patients would it be most appropriate for the nurse to use games during the assessment, such as having the patient “blow out” the light on the penlight? a. Infant b. Preschool child c. School-age child d. Adolescent B When assessing preschool children, using games or allowing them to play with the equipment to reduce their fears can be helpful. Such games are not appropriate for the other age groups.
32. The nurse is preparing to examine a 4 - year-old child. Which action is appropriate for this age group? a. Explain^ the^ procedures^ in^ detail^ to alleviate the child’s anxiety.

b. Give^ the^ child^ feedback^ and^ reassurance during the examination. c. Do^ not^ ask^ the^ child^ to^ remove^ his^ or^ her clothes because children at this age are usually very private. d. Perform an examination of the ear, nose, and throat first, and then examine the thorax and abdomen. B With preschool children, short, simple explanations should be used. Children at this age are usually willing to undress. An examination of the head should be performed last. During the examination, needed feedback and reassurance should be given to the preschooler.

33. When examining a 16 - year-old male teenager, the nurse should: a. Discuss^ health^ teaching^ with^ the^ parent because the teen is unlikely to be interested in promoting wellness. b. Ask^ his^ parent^ to^ stay^ in^ the^ room^ during the history and physical examination to answer any questions and to alleviate his anxiety. c. Talk to him the same manner as one would talk to a younger child because a teen’s level of understanding may not match his or her speech. d. Provide feedback that his body is developing normally, and discuss the wide variation among teenagers on the rate of growth and development. D During the examination, the adolescent needs feedback that his or her body is healthy and developing normally. The adolescent has a keen awareness of body image and often compares him or herself with peers. Apprise the adolescent of the wide variation among teenagers on the rate of growth and development.
34. When examining an older adult, the nurse should use which technique? a. Avoid touching the patient too much. b. Attempt^ to^ perform^ the^ entire^ physical examination during one visit. c. Speak loudly and slowly because most

aging adults have hearing deficits. d. Arrange^ the^ sequence^ of^ the^ examination to allow as few position changes as possible. D When examining the older adult, arranging the sequence of the examination to allow as few position changes as possible is best. Physical touch is especially important with the older person because other senses may be diminished.

35. The most important step that the nurse can take to prevent the transmission of microorganisms in the hospital setting is to: a. Wear protective eye wear at all times. b. Wear^ gloves^ during^ any^ and^ all contact with patients. c. Wash^ hands^ before^ and^ after^ contact with each patient. d. Clean^ the^ stethoscope^ with^ an^ alcohol swab between patients. C The most important step to decrease the risk of microorganism transmission is to wash hands promptly and thoroughly before and after physical contact with each patient. Stethoscopes should also be cleansed with an alcohol swab before and after each patient contact. The best routine is to combine stethoscope rubbing with hand hygiene each time hand hygiene is performed.
36. Which of these statements is true regarding the use of Standard Precautions in the health care setting? a. Standard^ Precautions^ apply^ to^ all^ body fluids, including sweat. b. Use^ alcohol-based^ hand^ rub^ if^ hands^ are visibly dirty. c. Standard Precautions are intended for use with all patients, regardless of their risk or presumed infection status. d. Standard Precautions are to be used only when nonintact skin, excretions containing visible blood, or expected contact with mucous membranes is present. C Standard Precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources and are intended for use for all patients,

regardless of their risk or presumed infection status. Standard Precautions apply to blood and all other body fluids, secretions and excretions except sweat—regardless of whether they contain visible blood, nonintact skin, or mucous membranes. Hands should be washed with soap and water if visibly soiled with blood or body fluids. Alcohol-based hand rubs can be used if hands are not visibly soiled.

37. The nurse is preparing to assess a hospitalized patient who is experiencing significant shortness of breath. How should the nurse proceed with the assessment? a. The^ patient^ should^ lie^ down^ to^ obtain^ an accurate cardiac, respiratory, and abdominal assessment. b. A thorough history and physical assessment information should be obtained from the patient’s family member. c. A complete history and physical assessment should be immediately performed to obtain baseline information. d. Body areas appropriate to the problem should be examined and then the assessment completed after the problem has resolved. D Both altering the position of the patient during the examination and collecting a mini database by examining the body areas appropriate to the problem may be necessary in this situation. An assessment may be completed later after the distress is resolved.
38. When examining an infant, the nurse should examine which area first? a. Ear b. Nose c. Throat d. Abdomen D The least-distressing steps are performed first, saving the invasive steps of the examination of the eye, ear, nose, and throat until last.
39. While auscultating heart sounds, the nurse hears a murmur. Which of these instruments should be used to assess this murmur? a. Electrocardiogram

b. Bell of the stethoscope c. Diaphragm of the stethoscope d. Palpation^ with^ the^ nurse’s^ palm^ of the hand B The bell of the stethoscope is best for soft, low-pitched sounds such as extra heart sounds or murmurs. The diaphragm of the stethoscope is best used for high-pitched sounds such as breath, bowel, and normal heart sounds.

40. During an examination of a patient’s abdomen, the nurse notes that the abdomen is rounded and firm to the touch. During percussion, the nurse notes a drumlike quality of the sounds across the quadrants. This type of sound indicates: a. Constipation. b. Air-filled^ areas. c. Presence of a tumor. d. Presence of dense organs. B A musical or drumlike sound (tympany) is heard when percussion occurs over an air- filled viscus, such as the stomach or intestines.
41. The nurse is preparing to examine a 6 - year-old child. Which action is most appropriate? a. The^ thorax,^ abdomen,^ and^ genitalia^ are examined before the head. b. Talking about the equipment being used is avoided because doing so may increase the child’s anxiety. c. The^ nurse^ should^ keep^ in^ mind^ that^ a^ child at this age will have a sense of modesty. d. The^ child^ is^ asked^ to^ undress^ from^ the waist up. C A 6-year-old child has a sense of modesty. The child should undress him or herself, leaving underpants on and using a gown or drape. A school-age child is curious to know how equipment works, and the sequence should progress from the child’s head to the toes.
42. During auscultation of a patient’s heart sounds, the nurse hears an unfamiliar sound. The nurse should:

a. Document^ the^ findings^ in^ the patient’s record. b. Wait^10 minutes,^ and^ auscultate^ the sound again. c. Ask the patient how he or she is feeling. d. Ask^ another^ nurse^ to^ double^ check^ the finding. D If an abnormal finding is not familiar, then the nurse may ask another examiner to double check the finding. The other responses do not help identify the unfamiliar sound. MULTIPLE RESPONSE

1. The nurse is preparing to palpate the thorax and abdomen of a patient. Which of these statements describes the correct technique for this procedure? Select all that apply. a. Warm^ the^ hands^ first^ before^ touching the patient. b. For deep palpation, use one long continuous palpation when assessing the liver. c. Start^ with^ light^ palpation^ to^ detect^ surface characteristics. d. Use^ the^ fingertips^ to^ examine^ skin^ texture, swelling, pulsation, and presence of lumps. e. Identify^ any^ tender^ areas,^ and^ palpate them last. f. Use^ the^ palms^ of^ the^ hands^ to^ assess temperature of the skin. A, C, D, E The hands should always be warmed before beginning palpation. Intermittent pressure rather than one long continuous palpation is used; any tender areas are identified and palpated last. Fingertips are used to examine skin texture, swelling, pulsation, and the presence of lumps. The dorsa (backs) of the hands are used to assess skin temperature because the skin on the dorsa is thinner than on the palms.

Chapter 09:

1. 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 A The general survey is a study of the whole person that includes observing the patient’s physical appearance, body structure, mobility, and behavior.
2. 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. D A standardized balance scale is used to measure weight. The patient should remove his or her shoes and heavy outer clothing. If a sequence of repeated weights is necessary, then the nurse should attempt to weigh the patient at approximately the same time of day and with the same types of clothing worn each time.
3. A patient’s weekly blood pressure readings for 2 months have ranged between 124/ 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 B According to the Seventh Report of the Joint National Committee (JNC 7) guidelines, prehypertension blood pressure readings are systolic readings of 120 to 139 mm Hg or diastolic readings of 50 to 89 mm Hg.

4. 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. A Physical growth is the best index of a child’s general health; recording the child’s height and weight helps determine normal growth patterns.
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: 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. B The newborn’s head measures approximately 32 to 38 cm and is approximately 2 cm larger than the chest circumference. Between 6 months and 2 years, both measurements are approximately the same, and after age 2 years, the chest circumference is greater than the head circumference.
6. 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 C Changes that occur in the aging person include more prominent bony landmarks, decreased body weight (especially in men), a decrease in subcutaneous fat from the face and periphery, and additional fat deposited on the abdomen and hips. Postural changes of kyphosis and slight flexion in the knees and hips also occur.

7. 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 C Rectal temperatures should be taken when the other routes are impractical, such as for comatose or confused persons, for those in shock, or for those who cannot close the mouth because of breathing or oxygen tubes, a wired mandible, or other facial dysfunctions.
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? 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 C To measure the chest circumference, the tape is encircled around the chest at the nipple line. The length should be measured on a horizontal measuring board. Weight should be measured on a platform-type balance scale. Head circumference is measured with the tape around the head, aligned at the eyebrows, and at the prominent frontal and occipital bones—the widest span is correct.
9. 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. A The TMT is useful for young children who may not cooperate for oral temperatures and fear rectal temperatures. However, the use a TMT with newborn infants and young children is conflicting.

10. 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 B With aging, the nurse keeps in mind that the systolic blood pressure increases, leading to widened pulse pressure. With many older people, both the systolic and diastolic pressures increase. The pulse rate and temperature do not increase.
11. 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 B The body maintains a steady temperature through a thermostat or feedback mechanism, which is regulated in the hypothalamus of the brain. The hypothalamus regulates heat production from metabolism, exercise, food digestion, and external factors with heat loss through radiation, evaporation of sweat, convection, and conduction.
12. 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. C Normal temperature is influenced by the diurnal cycle, exercise, and age. The other responses do not influence body temperature.

13. 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. A In older adults, the body temperature is usually lower than in other age groups, with a mean temperature of 36.2° C.
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: 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. C An unexplained weight loss may be a sign of a short-term illness or a chronic illness such as endocrine disease, malignancy, depression, anorexia nervosa, or bulimia.
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: 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. D Assuming a tripod position—leaning forward with arms braced on chair arms—occurs with chronic pulmonary disease. The other actions or assumptions are not correct.

16. 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 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. B The thermometer should be left in place 3 to 4 minutes if the person is afebrile and up to 8 minutes if the person is febrile. The nurse should wait 15 minutes if the person has just ingested hot or iced liquids and 2 minutes if he or she has just smoked. 17. 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. C The TMT is a noninvasive, nontraumatic device that is extremely quick and efficient. The chance of cross-contamination with the TMT is minimal because the ear canal is lined with skin, not mucous membranes.

18. 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. A A lubricated rectal thermometer (with a short, blunt tip) is inserted only 2 to 3 cm (1 inch) into the adult rectum and left in place for 2 minutes. Cigarette smoking does not alter rectal temperatures.
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. 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. A Recent research suggests that the 30 - second interval multiplied by 2 is the most accurate and efficient technique when heart rates are normal or rapid and when rhythms are regular. If the rhythm is irregular, then the pulse is counted for 1 full minute.
20. When assessing a patient’s pulse, the nurse should also notice which of these characteristics? a. Force