NUR2459 / NUR 2459: Final Exam Mental & Behavioral Health Nursing - Rasmussen
1
HEALTH ASSESSMENT EXAM 2
The nurse is performing a general survey. Which action is a component of the general
survey?
Observing the patient’s body stature and nutritional status
1. When measuring a patient’s weight, the nurse is aware of which of these
guidelines?
Attempts should be made to weigh the patient at approximately the same time of day,
if a sequence of weights is necessary.
2. A patient’s weekly blood pressure readings for 2 months have ranged between
124/84 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? Prehypertension
3. During an examination of a child, the nurse considers that physical growth is
the best index of a child’s: General health.
4. 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: Consider these findings normal for a 1-month-old infant.
5. The nurse is assessing an 80-year-old male patient. Which assessment findings
would be considered normal?
Presence of kyphosis and flexion in the knees and hips
6. The nurse should measure rectal temperatures in which of these patients?
Comatose adult
7. The nurse is preparing to measure the length, weight, chest, and head
circumference of a 6-month-old infant. Which measurement technique is
correct?
Measuring the chest circumference at the nipple line with a tape measure
8. The nurse knows that one advantage of the tympanic membrane thermometer
(TMT) is that: Rapid measurement is useful for uncooperative younger children.
1_________ NUR2459 / NUR 2459: FINAL EXAM MENTAL & BEHAVIORAL HEALTH NURSING – RASMUSSEN!______________#
,NUR2459 / NUR 2459: Final Exam Mental & Behavioral Health Nursing - Rasmussen
2
9. When assessing an older adult, which vital sign changes occur with aging?
Widened pulse pressure
10. The nurse is examining a patient who is complaining of feeling cold. Which is
a mechanism of heat loss in the body? Radiation
11. When measuring a patients body temperature, the nurse keeps in mind that
body temperature is influenced by:
Diurnal cycle.
12. When evaluating the temperature of older adults, the nurse should remember
which aspect about an older adult’s body temperature
The body temperature of the older adult is lower than that of a younger adult.
13. 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:
Unexplained weight loss often accompanies short-term illnesses.
14. 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:
d. Recognize that a tripod position is often used when a patient is having
respiratory difficulties.
15. Which of these actions illustrates the correct technique the nurse should use
when assessing oral temperature with a mercury thermometer?
b. Leave the thermometer in place 3 to 4 minutes if the patient is afebrile.
16. The nurse is taking temperatures in a clinic with a TMT. Which statement is
true regarding use of the TMT?
c. The risk of cross-contamination is reduced, compared with the rectal
route.
2_________ NUR2459 / NUR 2459: FINAL EXAM MENTAL & BEHAVIORAL HEALTH NURSING – RASMUSSEN!______________#
,NUR2459 / NUR 2459: Final Exam Mental & Behavioral Health Nursing - Rasmussen
3
17. To assess a rectal temperature accurately in an adult, the nurse would:
a. Use a lubricated blunt tip thermometer.
18. 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.
19. When assessing a patient’s pulse, the nurse should also notice which of these
characteristics?
Force
20. When assessing the pulse of a 6-year-old boy, the nurse notices that his heart
rate varies with his respiratory cycle, speeding up at the peak of inspiration and
slowing to normal with expiration. The nurses next action would be to:
b. Consider this finding normal in children and young adults.
21. When assessing the force, or strength, of a pulse, the nurse recalls that the
pulse:
c. Is a reflection of the hearts stroke volume.
22. The nurse is assessing the vital signs of a 20-year-old male marathon runner
and documents the following vital signs: temperature36 C; pulse48 beats per
minute; respirations14 breaths per minute; blood pressure104/68 mm Hg. Which
statement is true concerning these results?
b. These are normal vital signs for a healthy, athletic adult.
23. The nurse is assessing the vital signs of a 3-year-old patient who appears to
have an irregular respiratory pattern. How should the nurse assess this child’s
respirations?
a. Respirations should be counted for 1 full minute, noticing rate and
rhythm.
3_________ NUR2459 / NUR 2459: FINAL EXAM MENTAL & BEHAVIORAL HEALTH NURSING – RASMUSSEN!______________#
, NUR2459 / NUR 2459: Final Exam Mental & Behavioral Health Nursing - Rasmussen
4
24. A patient’s blood pressure is 118/82 mm Hg. He asks the nurse, what do the
numbers mean? The nurses best reply is:
c. The top number is the systolic blood pressure and reflects the pressure
of the blood against the arteries when the heart contracts.
25. While measuring a patient’s blood pressure, the nurse recalls that certain
factors, such as , help determine blood pressure.
d. Peripheral vascular resistance
26. A nurse is helping at a health fair at a local mall. When taking blood
pressures on a variety of people, the nurse keeps in mind that:
b. The blood pressure of a Black adult is usually higher than that of a
White adult of the same age.
27. The nurse notices a colleague is preparing to check the blood pressure of a
patient who is obese by using a standard-sized blood pressure cuff. The nurse
should expect the reading to:
b. Yield a falsely high blood pressure.
28. A student is late for his appointment and has rushed across campus to the
health clinic. The nurse should:
a. Allow 5 minutes for him to relax and rest before checking his vital
signs.
29. The nurse will perform a palpated pressure before auscultating blood
pressure. The reason for this is to:
b. Detect the presence of an auscultatory gap.
30. The nurse is taking an initial blood pressure reading on a 72-year-old patient
with documented hypertension. How should the nurse proceed?
4_________ NUR2459 / NUR 2459: FINAL EXAM MENTAL & BEHAVIORAL HEALTH NURSING – RASMUSSEN!______________#
1
HEALTH ASSESSMENT EXAM 2
The nurse is performing a general survey. Which action is a component of the general
survey?
Observing the patient’s body stature and nutritional status
1. When measuring a patient’s weight, the nurse is aware of which of these
guidelines?
Attempts should be made to weigh the patient at approximately the same time of day,
if a sequence of weights is necessary.
2. A patient’s weekly blood pressure readings for 2 months have ranged between
124/84 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? Prehypertension
3. During an examination of a child, the nurse considers that physical growth is
the best index of a child’s: General health.
4. 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: Consider these findings normal for a 1-month-old infant.
5. The nurse is assessing an 80-year-old male patient. Which assessment findings
would be considered normal?
Presence of kyphosis and flexion in the knees and hips
6. The nurse should measure rectal temperatures in which of these patients?
Comatose adult
7. The nurse is preparing to measure the length, weight, chest, and head
circumference of a 6-month-old infant. Which measurement technique is
correct?
Measuring the chest circumference at the nipple line with a tape measure
8. The nurse knows that one advantage of the tympanic membrane thermometer
(TMT) is that: Rapid measurement is useful for uncooperative younger children.
1_________ NUR2459 / NUR 2459: FINAL EXAM MENTAL & BEHAVIORAL HEALTH NURSING – RASMUSSEN!______________#
,NUR2459 / NUR 2459: Final Exam Mental & Behavioral Health Nursing - Rasmussen
2
9. When assessing an older adult, which vital sign changes occur with aging?
Widened pulse pressure
10. The nurse is examining a patient who is complaining of feeling cold. Which is
a mechanism of heat loss in the body? Radiation
11. When measuring a patients body temperature, the nurse keeps in mind that
body temperature is influenced by:
Diurnal cycle.
12. When evaluating the temperature of older adults, the nurse should remember
which aspect about an older adult’s body temperature
The body temperature of the older adult is lower than that of a younger adult.
13. 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:
Unexplained weight loss often accompanies short-term illnesses.
14. 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:
d. Recognize that a tripod position is often used when a patient is having
respiratory difficulties.
15. Which of these actions illustrates the correct technique the nurse should use
when assessing oral temperature with a mercury thermometer?
b. Leave the thermometer in place 3 to 4 minutes if the patient is afebrile.
16. The nurse is taking temperatures in a clinic with a TMT. Which statement is
true regarding use of the TMT?
c. The risk of cross-contamination is reduced, compared with the rectal
route.
2_________ NUR2459 / NUR 2459: FINAL EXAM MENTAL & BEHAVIORAL HEALTH NURSING – RASMUSSEN!______________#
,NUR2459 / NUR 2459: Final Exam Mental & Behavioral Health Nursing - Rasmussen
3
17. To assess a rectal temperature accurately in an adult, the nurse would:
a. Use a lubricated blunt tip thermometer.
18. 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.
19. When assessing a patient’s pulse, the nurse should also notice which of these
characteristics?
Force
20. When assessing the pulse of a 6-year-old boy, the nurse notices that his heart
rate varies with his respiratory cycle, speeding up at the peak of inspiration and
slowing to normal with expiration. The nurses next action would be to:
b. Consider this finding normal in children and young adults.
21. When assessing the force, or strength, of a pulse, the nurse recalls that the
pulse:
c. Is a reflection of the hearts stroke volume.
22. The nurse is assessing the vital signs of a 20-year-old male marathon runner
and documents the following vital signs: temperature36 C; pulse48 beats per
minute; respirations14 breaths per minute; blood pressure104/68 mm Hg. Which
statement is true concerning these results?
b. These are normal vital signs for a healthy, athletic adult.
23. The nurse is assessing the vital signs of a 3-year-old patient who appears to
have an irregular respiratory pattern. How should the nurse assess this child’s
respirations?
a. Respirations should be counted for 1 full minute, noticing rate and
rhythm.
3_________ NUR2459 / NUR 2459: FINAL EXAM MENTAL & BEHAVIORAL HEALTH NURSING – RASMUSSEN!______________#
, NUR2459 / NUR 2459: Final Exam Mental & Behavioral Health Nursing - Rasmussen
4
24. A patient’s blood pressure is 118/82 mm Hg. He asks the nurse, what do the
numbers mean? The nurses best reply is:
c. The top number is the systolic blood pressure and reflects the pressure
of the blood against the arteries when the heart contracts.
25. While measuring a patient’s blood pressure, the nurse recalls that certain
factors, such as , help determine blood pressure.
d. Peripheral vascular resistance
26. A nurse is helping at a health fair at a local mall. When taking blood
pressures on a variety of people, the nurse keeps in mind that:
b. The blood pressure of a Black adult is usually higher than that of a
White adult of the same age.
27. The nurse notices a colleague is preparing to check the blood pressure of a
patient who is obese by using a standard-sized blood pressure cuff. The nurse
should expect the reading to:
b. Yield a falsely high blood pressure.
28. A student is late for his appointment and has rushed across campus to the
health clinic. The nurse should:
a. Allow 5 minutes for him to relax and rest before checking his vital
signs.
29. The nurse will perform a palpated pressure before auscultating blood
pressure. The reason for this is to:
b. Detect the presence of an auscultatory gap.
30. The nurse is taking an initial blood pressure reading on a 72-year-old patient
with documented hypertension. How should the nurse proceed?
4_________ NUR2459 / NUR 2459: FINAL EXAM MENTAL & BEHAVIORAL HEALTH NURSING – RASMUSSEN!______________#
