GNRS 554-ADVANCED HEALTH ASSESSMENT AND DIAGNOSTIC REASONING EXAM 1| -REAL
ACTUAL EXAM-LATEST UPDATE 2025 | COMPLETE QUESTIONS WITH CORRECT DETAILED AND
VERIFIED ANSWERS | RATED 100% CORRECT!! ALREADY GRADED A+ | GUARANTEED PASS!!
1. The certified nursing assistant (CNA) provides you with change-of-shift vitals on your patients. Which patient should
you see FIRST?
A.84 year-old male with pneumonia, respiratory rate (RR) 28, oxygen saturation
(O2) 89%
B.54 year-old woman admitted after surgery for fractured arm, blood pressure
(BP) 160/86 mmHg, heart rate (HR) 72
C.63 year-old male with venous ulcers from diabetes temp 37.3C, HR 84 D.77 year-old woman with left mastectomy
2 days ago, RR 22, BP 148/62
mmHg: A.84 year-old male with pneumonia, respiratory rate (RR) 28, oxygen saturation (O2) 89%
2. What are the normal vital sign ranges for an adult?: BP: 120/80
RR: 12-20
Pulse: 60-100
Temp: 36-38C
SpO2: 95%+
3. When do you measure vital signs?: -When assessing a patient during home care visits
-In a clinic setting before a health care provider examines the patient and after any invasive procedures
-In a hospital on a routine schedule according to the health care provider's order or hospital standards of practice
-Before, during, and after a surgical procedure or invasive diagnostic/treatment procedure
,-Before, during, and after a transfusion of any type of blood product
-Before, during, and after the administration of medication or therapies that affect cardiovascular, respiratory, or
temperature-control functions
-When a patient's general physical condition changes (e.g., loss of consciousness or increased intensity of pain) -Before,
during, and after nursing interventions influencing a vital sign (e.g., before a patient previously on bed rest ambulates or
before a patient performs range-of-motion exercises)
-When a patient reports nonspecific symptoms of physical distress (e.g., feeling "funny" or "different")
4. What are factors that cause a change in body temp?: Age
Exercise
Hormonal level
Environment/stress
Circadian rhythm
Temperature alterations
5. How does age affect body temperature?: Temp regulation is unstable in pre pubertal children
Older adults are more sensitive to temp extremes and have a narrower range for normal
6. How do hormonal levels affect body temperature?: Women have more temperature fluctuations than men progesterone
increases temp
7. How does environment/stress affect body temperature?: Ambient temp impacts body temp
Increased stress increases body temp
8. How does exercise affect body temperature?: Exercise increases body temp
9. How does circadian rhythm affect body temperature?: Body temp lowest 1-4 am, peaks 12-4 pm
,10. Body temp = heat ____ - heat ____: Body temp = heat produced - heat lost
11. Which organ controls body temp: Hypothalamus
12. What are ways the body produces heat?: Shivering, vasoconstriction, increased metabolism
13. What are ways the body loses heat?: Diaphoresis, vasodilation, decreased metabolism
14. Temperature sites: Oral, rectal, axillary, tympanic membrane, temporal artery, skin
15. Temp site to use for infants: Rectal
16. Temp site to use for pt with upper respiratory congestion: Axillary or rectal
17. Temp site to use for pt having a seizure: Axillary or Tympanic
18. Most accurate temperature site: rectal
19. Least accurate temperature site: axillary
20. You have delegated vital signs to assistive personnel. The assistant informs you that the patient has just finished a
bowl of hot soup, but appears to be in no apparent distress. The nurse's most appropriate advice would be to do what?
A. Take a rectal temperature.
B. Take the oral temperature as planned.
C. Advise the patient to drink a glass of cold water.
D. Wait 30 minutes and take an oral temperature.: D. Wait 30 minutes and take an oral temperature.
21. What is pyrexia?: Fever
Heat-loss mechanisms are unable to keep up with excessive heat production
Alteration in hypothalamic set point, pyrogens trigger immune system
22. Does a single high temperature reading always indicate a fever?: No
23. Febrile vs afebrile: fever vs no fever
, 24. Is fever good?: Sometimes!
Enhances immune system: increases WBC production, decreases growth of bacteria and viruses
BUT also increases metabolic and O2 needs
25. Where are the pulse sites?: Temporal, carotid, brachial, radial, ulnar, apical, femoral, popliteal, tibial, dorsal pedis
26. Discuss physiological changes associated with fever.: Vasodilation, sweating, inhibition
of heat production. Hypothalamus raises set point of internal temp and body produces/conserves heat. Chills, shivers,
and feeling cold as body goes to new set point. Increased heart and respiratory rates
27. What is conduction in heat loss?: The transfer of heat from one object to another with direct contact.
(touching a cold table with warm hand)
28. What is evaporation in heat loss?: The transfer of heat energy when a liquid is changed to a gas.
The body continuously loses heat by evaporation. (perspiration/sweating)
29. What is diaphoresis in heat loss?: Visible perspiration
30. What are the patterns of fever?: -Sustained: A constant body temperature continuously above 38°C
(100.4°F) that has little fluctuation
-Intermittent: Fever spikes interspersed with usual temperature levels (Temperature returns to acceptable value at least
once in 24 hours.)
-Relapsing: Periods of febrile episodes and periods with acceptable temperature values (Febrile episodes and periods of
normothermia are often longer than 24 hours.)
ACTUAL EXAM-LATEST UPDATE 2025 | COMPLETE QUESTIONS WITH CORRECT DETAILED AND
VERIFIED ANSWERS | RATED 100% CORRECT!! ALREADY GRADED A+ | GUARANTEED PASS!!
1. The certified nursing assistant (CNA) provides you with change-of-shift vitals on your patients. Which patient should
you see FIRST?
A.84 year-old male with pneumonia, respiratory rate (RR) 28, oxygen saturation
(O2) 89%
B.54 year-old woman admitted after surgery for fractured arm, blood pressure
(BP) 160/86 mmHg, heart rate (HR) 72
C.63 year-old male with venous ulcers from diabetes temp 37.3C, HR 84 D.77 year-old woman with left mastectomy
2 days ago, RR 22, BP 148/62
mmHg: A.84 year-old male with pneumonia, respiratory rate (RR) 28, oxygen saturation (O2) 89%
2. What are the normal vital sign ranges for an adult?: BP: 120/80
RR: 12-20
Pulse: 60-100
Temp: 36-38C
SpO2: 95%+
3. When do you measure vital signs?: -When assessing a patient during home care visits
-In a clinic setting before a health care provider examines the patient and after any invasive procedures
-In a hospital on a routine schedule according to the health care provider's order or hospital standards of practice
-Before, during, and after a surgical procedure or invasive diagnostic/treatment procedure
,-Before, during, and after a transfusion of any type of blood product
-Before, during, and after the administration of medication or therapies that affect cardiovascular, respiratory, or
temperature-control functions
-When a patient's general physical condition changes (e.g., loss of consciousness or increased intensity of pain) -Before,
during, and after nursing interventions influencing a vital sign (e.g., before a patient previously on bed rest ambulates or
before a patient performs range-of-motion exercises)
-When a patient reports nonspecific symptoms of physical distress (e.g., feeling "funny" or "different")
4. What are factors that cause a change in body temp?: Age
Exercise
Hormonal level
Environment/stress
Circadian rhythm
Temperature alterations
5. How does age affect body temperature?: Temp regulation is unstable in pre pubertal children
Older adults are more sensitive to temp extremes and have a narrower range for normal
6. How do hormonal levels affect body temperature?: Women have more temperature fluctuations than men progesterone
increases temp
7. How does environment/stress affect body temperature?: Ambient temp impacts body temp
Increased stress increases body temp
8. How does exercise affect body temperature?: Exercise increases body temp
9. How does circadian rhythm affect body temperature?: Body temp lowest 1-4 am, peaks 12-4 pm
,10. Body temp = heat ____ - heat ____: Body temp = heat produced - heat lost
11. Which organ controls body temp: Hypothalamus
12. What are ways the body produces heat?: Shivering, vasoconstriction, increased metabolism
13. What are ways the body loses heat?: Diaphoresis, vasodilation, decreased metabolism
14. Temperature sites: Oral, rectal, axillary, tympanic membrane, temporal artery, skin
15. Temp site to use for infants: Rectal
16. Temp site to use for pt with upper respiratory congestion: Axillary or rectal
17. Temp site to use for pt having a seizure: Axillary or Tympanic
18. Most accurate temperature site: rectal
19. Least accurate temperature site: axillary
20. You have delegated vital signs to assistive personnel. The assistant informs you that the patient has just finished a
bowl of hot soup, but appears to be in no apparent distress. The nurse's most appropriate advice would be to do what?
A. Take a rectal temperature.
B. Take the oral temperature as planned.
C. Advise the patient to drink a glass of cold water.
D. Wait 30 minutes and take an oral temperature.: D. Wait 30 minutes and take an oral temperature.
21. What is pyrexia?: Fever
Heat-loss mechanisms are unable to keep up with excessive heat production
Alteration in hypothalamic set point, pyrogens trigger immune system
22. Does a single high temperature reading always indicate a fever?: No
23. Febrile vs afebrile: fever vs no fever
, 24. Is fever good?: Sometimes!
Enhances immune system: increases WBC production, decreases growth of bacteria and viruses
BUT also increases metabolic and O2 needs
25. Where are the pulse sites?: Temporal, carotid, brachial, radial, ulnar, apical, femoral, popliteal, tibial, dorsal pedis
26. Discuss physiological changes associated with fever.: Vasodilation, sweating, inhibition
of heat production. Hypothalamus raises set point of internal temp and body produces/conserves heat. Chills, shivers,
and feeling cold as body goes to new set point. Increased heart and respiratory rates
27. What is conduction in heat loss?: The transfer of heat from one object to another with direct contact.
(touching a cold table with warm hand)
28. What is evaporation in heat loss?: The transfer of heat energy when a liquid is changed to a gas.
The body continuously loses heat by evaporation. (perspiration/sweating)
29. What is diaphoresis in heat loss?: Visible perspiration
30. What are the patterns of fever?: -Sustained: A constant body temperature continuously above 38°C
(100.4°F) that has little fluctuation
-Intermittent: Fever spikes interspersed with usual temperature levels (Temperature returns to acceptable value at least
once in 24 hours.)
-Relapsing: Periods of febrile episodes and periods with acceptable temperature values (Febrile episodes and periods of
normothermia are often longer than 24 hours.)
