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Terms in this set (52)
The nurse is performing a A
general survey. Which The general survey is a study of the whole person that
action is a component of includes observing the patient's physical appearance,
the general survey? body structure, mobility, and behavior.
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
,When measuring a D
patient's weight, the nurse A standardized balance scale is used to measure
is aware of which of these weight. The patient should remove his or her shoes
guidelines? and heavy outer clothing. If a sequence of repeated
a.The patient is always weights is necessary, then the nurse should attempt to
weighed wearing only his weigh the patient at approximately the same time of
or her undergarments. day and with the same types of clothing worn each
b.The type of scale does time.
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.
A patient's weekly blood B
pressure readings for 2 According to the Seventh Report of the Joint National
months have ranged Committee (JNC 7) guidelines, prehypertension blood
between 124/84 mm Hg pressure readings are systolic readings of 120 to 139
and 136/88 mm Hg, with mm Hg or diastolic readings of 50 to 89 mm Hg.
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
,During an examination of A
a child, the nurse Physical growth is the best index of a child's general
considers that physical health; recording the child's height and weight helps
growth is the best index of determine normal growth patterns.
a child's:
a.General health.
b.Genetic makeup.
c.Nutritional status.
d.Activity and exercise
patterns.
A 1-month-old infant has a B
head measurement of 34 The newborn's head measures approximately 32 to 38
cm and has a chest cm and is approximately 2 cm larger than the chest
circumference of 32 cm. circumference. Between 6 months and 2 years, both
Based on the measurements are approximately the same, and after
interpretation of these age 2 years, the chest circumference is greater than
findings, the nurse would: the head circumference
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.
, The nurse is assessing an C
80-year-old male patient. Changes that occur in the aging person include more
Which assessment findings prominent bony landmarks, decreased body weight
would be considered (especially in men), a decrease in subcutaneous fat
normal? from the face and periphery, and additional fat
a.Increase in body weight deposited on the abdomen and hips. Postural
from his younger years changes of kyphosis and slight flexion in the knees
b.Additional deposits of and hips also occur.
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
The nurse should measure C
rectal temperatures in Rectal temperatures should be taken when the other
which of these patients? routes are impractical, such as for comatose or
a.School-age child confused persons, for those in shock, or for those
b.Older adult who cannot close the mouth because of breathing or
c.Comatose adult oxygen tubes, a wired mandible, or other facial
d.Patient receiving oxygen dysfunctions.
by nasal cannula