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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 ✔Correct 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. ✔Correct 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 ✔Correct 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. ✔Correct 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. ✔Correct
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 ✔Correct 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 ✔Correct 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 ✔Correct 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. ✔Correct
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 ✔Correct 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 ✔Correct 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 ✔Correct 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 ✔Correct Answer-A