CHAPTER 9

Question 1

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

Answer 1

ANS: A
The general survey is a study of the whole person that includes observing the patient’s physical appearance, body structure, mobility, and behavior

Question 2

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.
   The patient may leave on his or her jacket and shoes as long as these are documented next
   c. to the weight.
   Attempts should be made to weigh the patient at approximately the same time of day, if a
   d. sequence of weights is necessary.

Answer 2

ANS: 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

Question 3

3. 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?
   a. Normal blood pressure
   b. Prehypertension
   c. Stage 1 hypertension
   d. Stage 2 hypertension

Answer 3

ANS: 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.

Question 4

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.

Answer 4

ANS: A
Physical growth is the best index of a child’s general health; recording the child’s height a weight helps determine normal growth patterns

Question 5

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.

Answer 5

ANS: 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.

Question 6

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

Answer 6

ANS: 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

Question 7

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

Answer 7

ANS: 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

Question 8

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
   Measuring the head circumference by wrapping the tape measure over the nose and
   d. cheekbones

Answer 8

ANS: 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.

Question 9

9. The nurse knows that one advantage of the tympanic membrane thermometer (TMT) is that:
   a. Rapid measurement is useful for uncooperative younger children.
   Using the TMT is the most accurate method for measuring body temperature in newborn
   b. 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.
   temperatures. However, the use a TMT with newborn infants and young children is conflicting.

Answer 9

ANS: A

The TMT is useful for young children who may not cooperate for oral temperatures and fear rectal

Question 10

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

Answer 10

ANS: 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.

Question 11

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

Answer 11

ANS: 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.

Question 12

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.

Answer 12

Normal temperature is influenced by the diurnal cycle, exercise, and age. The other responses do not influence body temperature.

Question 13

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.
    In the older adult, the body temperature varies widely because of less effective heat control
    d. mechanisms.

Answer 13

ANS: A

In older adults, the body temperature is usually lower than in other age groups, with a mean temperature of 36.2° C.

Question 14

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.

Answer 14

ANS: 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.

Question 15

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.
    Recognize that a tripod position is often used when a patient is having respiratory
    d. difficulties.

Answer 15

ANS: 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.

Question 16

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.
    Shake the mercury-in-glass thermometer down to below 36.6° C before taking the
    d. temperature.

Answer 16

ANS: 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.

Question 17

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.

Answer 17

ANS: 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.

Question 18

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.

Answer 18

ANS: 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.

Question 19

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.

Answer 19

ANS: 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.

Question 20

20. When assessing a patient’s pulse, the nurse should also notice which of these characteristics?
    a. Force
    b. Pallor
    c. Capillary refill time
    d. Timing in the cardiac cycle

Answer 20

ANS: A

The pulse is assessed for rate, rhythm, and force

Question 21

21. 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 nurse’s next action would be to:
    a. Immediately notify the physician.
    b. Consider this finding normal in children and young adults.
    c. Check the child’s blood pressure, and note any variation with respiration.
    d. Document that this child has bradycardia, and continue with the assessment.

Answer 21

ANS: B
Sinus arrhythmia is commonly found in children and young adults. During the respiratory cycle, the heart rate varies, speeding up at the peak of inspiration and slowing to normal with expiration.

Question 22

22. When assessing the force, or strength, of a pulse, the nurse recalls that the pulse:
    a. Is usually recorded on a 0- to 2-point scale.
    b. Demonstrates elasticity of the vessel wall.
    c. Is a reflection of the heart’s stroke volume.
    d. Reflects the blood volume in the arteries during diastole.

Answer 22

ANS: C
The heart pumps an amount of blood (the stroke volume) into the aorta. The force flares the arterial walls and generates a pressure wave, which is felt in the periphery as the pulse.

Question 23

23. The nurse is assessing the vital signs of a 20-year-old male marathon runner and documents the following vital signs: temperature–36° C; pulse–48 beats per minute; respirations–14 breaths per minute; blood pressure–104/68 mm Hg. Which statement is true concerning these results?

a. The patient is experiencing tachycardia.
b. These are normal vital signs for a healthy, athletic adult.
c. The patient’s pulse rate is not normal—his physician should be notified.
d. On the basis of these readings, the patient should return to the clinic in 1 week.

Answer 23

ANS: B
In the adult, a heart rate less than 50 beats per minute is called bradycardia, which normally occurs in the well-trained athlete whose heart muscle develops along with the skeletal muscles.

Question 24

24. 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.
    b. Child’s pulse and respirations should be simultaneously checked for 30 seconds.
    Child’s respirations should be checked for a minimum of 5 minutes to identify any
    c. variations in his or her respiratory pattern.
    Patient’s respirations should be counted for 15 seconds and then multiplied by 4 to obtain
    d. the number of respirations per minute.

Answer 24

ANS: A

Respirations are counted for 1 full minute if an abnormality is suspected. The other responses are not correct actions.

Question 25

25. A patient’s blood pressure is 118/82 mm Hg. He asks the nurse, “What do the numbers mean?” The nurse’s best reply is:
    a. “The numbers are within the normal range and are nothing to worry about.”
    b. “The bottom number is the diastolic pressure and reflects the stroke volume of the heart.”
    c.”The top number is the systolic blood pressure and reflects the pressure of the blood against the arteries when the heart contracts.”
    “The concept of blood pressure is difficult to understand. The primary thing to be concerned d. about is the top number, or the systolic blood pressure

Answer 25

ANS: C
The systolic pressure is the maximum pressure felt on the artery during left ventricular contraction, or systole. The diastolic pressure is the elastic recoil, or resting, pressure that the blood constantly exerts in between each contraction. The nurse should answer the patient’s question and use terms he can understand.

Question 26

26. While measuring a patient’s blood pressure, the nurse recalls that certain factors, such as __________, help determine blood pressure.
    a. Pulse rate
    b. Pulse pressure
    c. Vascular output
    d. Peripheral vascular resistance

Answer 26

ANS: D
The level of blood pressure is determined by five factors: cardiac output, peripheral vascular resistance, volume of circulating blood, viscosity, and elasticity of the vessel walls.

Question 27

27. 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:
    After menopause, blood pressure readings in women are usually lower than those taken in
    a. men.
    The blood pressure of a Black adult is usually higher than that of a White adult of the same
    b. age.
    Blood pressure measurements in people who are overweight should be the same as those of
    c. people who are at a normal weight.
    d. A teenager’s blood pressure reading will be lower than that of an adult.

Answer 27

ANS: B
In the United States, a Black adult’s blood pressure is usually higher than that of a White adult of the same age. The incidence of hypertension is twice as high in Blacks as it is in Whites. After menopause, blood pressure in women is higher than in men; blood pressure measurements in people who are obese are usually higher than in those who are not overweight. Normally, a gradual rise occurs through childhood and into the adult years.

Question 28

28. 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:
    a. Yield a falsely low blood pressure.
    b. Yield a falsely high blood pressure.
    c. Be the same, regardless of cuff size.
    d. Vary as a result of the technique of the person performing the assessment.

Answer 28

ANS: B
Using a cuff that is too narrow yields a falsely high blood pressure because it takes extra pressure to compress the artery.

Question 29

29. 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.
    Check the blood pressure in both arms, expecting a difference in the readings because of his
    b. recent exercise.
    Immediately monitor his vital signs on his arrival at the clinic and then 5 minutes later,
    c. recording any differences.
    Check his blood pressure in the supine position, which will provide a more accurate reading
    d. and will allow him to relax at the same time.

Answer 29

ANS: A
A comfortable, relaxed person yields a valid blood pressure. Many people are anxious at the beginning of an examination; the nurse should allow at least a 5-minute rest period before measuring blood pressure.

Question 30

30. The nurse will perform a palpated pressure before auscultating blood pressure. The reason for this is to:
    a. More clearly hear the Korotkoff sounds.
    b. Detect the presence of an auscultatory gap.
    c. Avoid missing a falsely elevated blood pressure.
    d. More readily identify phase IV of the Korotkoff sounds.

Answer 30

ANS: B
Inflation of the cuff 20 to 30 mm Hg beyond the point at which a palpated pulse disappears will avoid missing an auscultatory gap, which is a period when the Korotkoff sounds disappear during auscultation.

Question 31

31. The nurse is taking an initial blood pressure reading on a 72-year-old patient with documented hypertension. How should the nurse proceed?
    Cuff should be placed on the patient’s arm and inflated 30 mm Hg above the patient’s pulse
    a. rate.
    Cuff should be inflated to 200 mm Hg in an attempt to obtain the most accurate systolic
    b. reading.
    c. Cuff should be inflated 30 mm Hg above the point at which the palpated pulse disappears.
    After confirming the patient’s previous blood pressure readings, the cuff should be inflated
    d. 30 mm Hg above the highest systolic reading recorded.

Answer 31

ANS: C
An auscultatory gap occurs in approximately 5% of the people, most often in those with hypertension. To check for the presence of an auscultatory gap, the cuff should be inflated 20 to 30 mm Hg beyond the point at which the palpated pulse disappears.

Question 32

32. The nurse has collected the following information on a patient: palpated blood pressure–180 mm Hg; auscultated blood pressure–170/100 mm Hg; apical pulse–60 beats per minute; radial pulse–70 beats per minute. What is the patient’s pulse pressure?
    a. 10 b. 70 c. 80 d. 100

Answer 32

ANS: B
Pulse pressure is the difference between systolic and diastolic blood pressure (170 – 100 = 70) and reflects the stroke volume.

Question 33

33. When auscultating the blood pressure of a 25-year-old patient, the nurse notices the phase I Korotkoff sounds begin at 200 mm Hg. At 100 mm Hg, the Korotkoff sounds muffle. At 92 mm Hg, the Korotkoff sounds disappear. How should the nurse record this patient’s blood pressure?
    a. 200/92
    b. 200/100
    c. 100/200/92 d. 200/100/92

Answer 33

ANS: A
In adults, the last audible sound best indicates the diastolic pressure. When a variance is greater than 10 to 12 mm Hg between phases IV and V, both phases should be recorded along with the systolic reading (e.g., 142/98/80).

Question 34

34. A patient is seen in the clinic for complaints of “fainting episodes that started last week.” How should the nurse proceed with the examination?
    a. Blood pressure readings are taken in both the arms and the thighs.
    b. The patient is assisted to a lying position, and his blood pressure is taken.
    c. His blood pressure is recorded in the lying, sitting, and standing positions.
    His blood pressure is recorded in the lying and sitting positions; these numbers are then
    d. averaged to obtain a mean blood pressure.

Answer 34

ANS: C
If the person is known to have hypertension, is taking antihypertensive medications, or reports a history of fainting or syncope, then the blood pressure reading should be taken in three positions: lying, sitting, and standing.

Question 35

35. A 70-year-old man has a blood pressure of 150/90 mm Hg in a lying position, 130/80 mm Hg in a sitting position, and 100/60 mm Hg in a standing position. How should the nurse evaluate these findings?
    a. These readings are a normal response and attributable to changes in the patient’s position.
    b. The change in blood pressure readings is called orthostatic hypotension.
    c. The blood pressure reading in the lying position is within normal limits.
    The change in blood pressure readings is considered within normal limits for the patient’s
    d. age.

Answer 35

ANS: B
Orthostatic hypotension is a drop in systolic pressure of more than 20 mm Hg, which occurs with a quick change to a standing position. Aging people have the greatest risk of this problem.

Question 36

36. The nurse is helping another nurse to take a blood pressure reading on a patient’s thigh. Which action is correct regarding thigh pressure?
    a. Either the popliteal or femoral vessels should be auscultated to obtain a thigh pressure.
    The best position to measure thigh pressure is the supine position with the knee slightly
    b. bent.
    If the blood pressure in the arm is high in an adolescent, then it should be compared with
    c. the thigh pressure.
    The thigh pressure is lower than the pressure in the arm, which is attributable to the distance
    d. away from the heart and the size of the popliteal vessels.

Answer 36

ANS: C
When blood pressure measured at the arm is excessively high, particularly in adolescents and young adults, it is compared with thigh pressure to check for coarctation of the aorta. The popliteal artery is auscultated for the reading. Generally, thigh pressure is higher than that of the arm; however, if coarctation of the artery is present, then arm pressures are higher than thigh pressures.

Question 37

37. The nurse is preparing to measure the vital signs of a 6-month-old infant. Which action by the nurse is correct?
    a. Respirations are measured; then pulse and temperature.
    b. Vital signs should be measured more frequently than in an adult.
    Procedures are explained to the parent, and the infant is encouraged to handle the
    c. equipment.
    The nurse should first perform the physical examination to allow the infant to become more
    d. familiar with her and then measure the infant’s vital signs.

Answer 37

ANS: A
With an infant, the order of vital sign measurements is reversed to respiration, pulse, and temperature. Taking the temperature first, especially if it is rectal, may cause the infant to cry, which will increase the respiratory and pulse rate, thus masking the normal resting values. The vital signs are measured with the same purpose and frequency as would be measured in an adult.

Question 38

38. A 4-month-old child is at the clinic for a well-baby check-up and immunizations. Which of these actions is most appropriate when the nurse is assessing an infant’s vital signs?
    The infant’s radial pulse should be palpated, and the nurse should notice any fluctuations
    a. resulting from activity or exercise.
    The nurse should auscultate an apical rate for 1 minute and then assess for any normal
    b. irregularities, such as sinus arrhythmia.
    The infant’s blood pressure should be assessed by using a stethoscope with a large
    c. diaphragm piece to hear the soft muffled Korotkoff sounds.
    The infant’s chest should be observed and the respiratory rate counted for 1 minute; the
    d. respiratory pattern may vary significantly.

Answer 38

ANS: B
The nurse palpates or auscultates an apical rate with infants and toddlers. The pulse should be counted for 1 full minute to account for normal irregularities, such as sinus arrhythmia. Children younger than 3 years of age have such small arm vessels; consequently, hearing Korotkoff sounds with a stethoscope is difficult. The nurse should use either an electronic blood pressure device that uses oscillometry or a Doppler ultrasound device to amplify the sounds.

Question 39

38. A 4-month-old child is at the clinic for a well-baby check-up and immunizations. Which of these actions is most appropriate when the nurse is assessing an infant’s vital signs?
    The infant’s radial pulse should be palpated, and the nurse should notice any fluctuations
    a. resulting from activity or exercise.
    The nurse should auscultate an apical rate for 1 minute and then assess for any normal
    b. irregularities, such as sinus arrhythmia.
    The infant’s blood pressure should be assessed by using a stethoscope with a large
    c. diaphragm piece to hear the soft muffled Korotkoff sounds.
    The infant’s chest should be observed and the respiratory rate counted for 1 minute; the
    d. respiratory pattern may vary significantly.

Answer 39

ANS: B
The nurse palpates or auscultates an apical rate with infants and toddlers. The pulse should be counted for 1 full minute to account for normal irregularities, such as sinus arrhythmia. Children younger than 3 years of age have such small arm vessels; consequently, hearing Korotkoff sounds with a stethoscope is difficult. The nurse should use either an electronic blood pressure device that uses oscillometry or a Doppler ultrasound device to amplify the sounds.

Question 40

39. The nurse is conducting a health fair for older adults. Which statement is true regarding vital sign measurements in aging adults?
    a. The pulse is more difficult to palpate because of the stiffness of the blood vessels.
    b. An increased respiratory rate and a shallower inspiratory phase are expected findings.
    A decreased pulse pressure occurs from changes in the systolic and diastolic blood
    c. pressures.
    Changes in the body’s temperature regulatory mechanism leave the older person more
    d. likely to develop a fever.

Answer 40

ANS: B
Aging causes a decrease in vital capacity and decreased inspiratory reserve volume. The examiner may notice a shallower inspiratory phase and an increased respiratory rate. An increase in the rigidity of the arterial walls makes the pulse actually easier to palpate. Pulse pressure is widened in older adults, and changes in the body temperature regulatory mechanism leave the older person less likely to have fever but at a greater risk for hypothermia.

Question 41

40. In a patient with acromegaly, the nurse will expect to discover which assessment findings?
    a. Heavy, flattened facial features
    b. Growth retardation and a delayed onset of puberty
    c. Overgrowth of bone in the face, head, hands, and feet
    d. Increased height and weight and delayed sexual development

Answer 41

ANS: C
Excessive secretions of growth hormone in adulthood after normal completion of body growth causes an overgrowth of the bones in the face, head, hands, and feet but no change in height.

Question 42

41. The nurse is performing a general survey of a patient. Which finding is considered normal?
    a. When standing, the patient’s base is narrow.
    b. The patient appears older than his stated age.
    c. Arm span (fingertip to fingertip) is greater than the height.
    d. Arm span (fingertip to fingertip) equals the patient’s height.

Answer 42

ANS: D
When performing the general survey, the patient’s arm span (fingertip to fingertip) should equal the patient’s height. An arm span that is greater than the person’s height may indicate Marfan syndrome. The base should be wide when the patient is standing, and an older appearance than the stated age may indicate a history of a chronic illness or chronic alcoholism.

Question 43

42. The nurse is assessing children in a pediatric clinic. Which statement is true regarding the measurement of blood pressure in children?
    a. Blood pressure guidelines for children are based on age.
    b. Phase II Korotkoff sounds are the best indicator of systolic blood pressure in children.
    Using a Doppler device is recommended for accurate blood pressure measurements until
    c. adolescence.
    The disappearance of phase V Korotkoff sounds can be used for the diastolic reading in
    d. children.

Answer 43

ANS: D

The disappearance of phase V Korotkoff sounds can be used for the diastolic reading in children, as well as in adults.

Question 44

43. What type of blood pressure measurement error is most likely to occur if the nurse does not check for the presence of an auscultatory gap?
    a. Diastolic blood pressure may not be heard.
    b. Diastolic blood pressure may be falsely low.
    c. Systolic blood pressure may be falsely low.
    d. Systolic blood pressure may be falsely high.

Answer 44

ANS: C
If an auscultatory gap is undetected, then a falsely low systolic or falsely high diastolic reading may result, which is common in patients with hypertension.

Question 45

44. When considering the concepts related to blood pressure, the nurse knows that the concept of mean arterial pressure (MAP) is best described by which statement?
    a. MAP is the pressure of the arterial pulse.
    b. MAP reflects the stroke volume of the heart.
    c. MAP is the pressure forcing blood into the tissues, averaged over the cardiac cycle.
    d. MAP is an average of the systolic and diastolic blood pressures and reflects tissue perfusion.

Answer 45

ANS: C
MAP is the pressure that forces blood into the tissues, averaged over the cardiac cycle. Stroke volume is reflected by the blood pressure. MAP is not an arithmetic average of systolic and diastolic pressures because diastole lasts longer; rather, it is a value closer to diastolic pressure plus one third of the pulse pressure.

Question 46

45. A 75-year-old man with a history of hypertension was recently changed to a new antihypertensive drug. He reports feeling dizzy at times. How should the nurse evaluate his blood pressure?
    a. Blood pressure and pulse should be recorded in the supine, sitting, and standing positions.
    The patient should be directed to walk around the room and his blood pressure assessed
    b. after this activity.
    c. Blood pressure and pulse are assessed at the beginning and at the end of the examination.
    d. Blood pressure is taken on the right arm and then 5 minutes later on the left arm.

Answer 46

ANS: A
Orthostatic vital signs should be taken when the person is hypertensive or is taking antihypertensive medications, when the person reports fainting or syncope, or when volume depletion is suspected. The blood pressure and pulse readings are recorded in the supine, sitting, and standing positions.

Question 47

46. Which of these specific measurements is the best index of a child’s general health?
    a. Vital signs
    b. Height and weight
    c. Head circumference
    d. Chest circumference

Answer 47

ANS: B

Physical growth, measured by height and weight, is the best index of a child’s general health.

Question 48

46. Which of these specific measurements is the best index of a child’s general health?
    a. Vital signs
    b. Height and weight
    c. Head circumference
    d. Chest circumference

ANS: B
Physical growth, measured by height and weight, is the best index of a child’s general health.

Answer 48

ANS: B

Physical growth, measured by height and weight, is the best index of a child’s general health.

Question 49

47. The nurse is assessing an 8-year-old child whose growth rate measures below the third percentile for a child his age. He appears significantly younger than his stated age and is chubby with infantile facial features. Which condition does this child have?
    a. Hypopituitary dwarfism
    b. Achondroplastic dwarfism
    c. Marfan syndrome
    d. Acromegaly

Answer 49

ANS: A
Hypopituitary dwarfism is caused by a deficiency in growth hormone in childhood and results in a retardation of growth below the third percentile, delayed puberty, and other problems. The child’s appearance fits this description. Achondroplastic dwarfism is a genetic disorder resulting in characteristic deformities; Marfan syndrome is an inherited connective tissue disorder characterized by a tall, thin stature and other features. Acromegaly is the result of excessive secretion of growth hormone in adulthood. (For more information, see Table 9-5, Abnormalities in Body Height and Proportion.)

Question 50

48. The nurse is counting an infant’s respirations. Which technique is correct?
    a. Watching the chest rise and fall
    b. Watching the abdomen for movement
    c. Placing a hand across the infant’s chest
    d. Using a stethoscope to listen to the breath sounds

Answer 50

ANS: B
Watching the abdomen for movement is the correct technique because the infant’s respirations are normally more diaphragmatic than thoracic. The other responses do not reflect correct techniques.

Question 51

49. When checking for proper blood pressure cuff size, which guideline is correct?
    a. The standard cuff size is appropriate for all sizes.
    b. The length of the rubber bladder should equal 80% of the arm circumference.
    c. The width of the rubber bladder should equal 80% of the arm circumference.
    d. The width of the rubber bladder should equal 40% of the arm circumference.

Answer 51

ANS: D
The width of the rubber bladder should equal 40% of the circumference of the person’s arm. The length of the bladder should equal 80% of this circumference.

Question 52

50. During an examination, the nurse notices that a female patient has a round “moon” face, central trunk obesity, and a cervical hump. Her skin is fragile with bruises. The nurse determines that the patient has which condition?
    a. Marfan syndrome
    b. Gigantism
    c. Cushing syndrome
    d. Acromegaly

Answer 52

ANS: C
Cushing syndrome is characterized by weight gain and edema with central trunk and cervical obesity (buffalo hump) and round plethoric face (moon face). Excessive catabolism causes muscle wasting; weakness; thin arms and legs; reduced height; and thin, fragile skin with purple abdominal striae, bruising, and acne. (See Table 9-5, Abnormalities in Body Height and Proportion, for the definitions of the other conditions.)

Question 53

1. While measuring a patient’s blood pressure, the nurse uses the proper technique to obtain an accurate reading. Which of these situations will result in a falsely high blood pressure reading? Select all that apply.
   a. The person supports his or her own arm during the blood pressure reading.
   b. The blood pressure cuff is too narrow for the extremity.
   c. The arm is held above level of the heart.
   d. The cuff is loosely wrapped around the arm.
   e. The person is sitting with his or her legs crossed.
   f. The nurse does not inflate the cuff high enough.

Answer 53

ANS: A, B, D, E
Several factors can result in blood pressure readings that are too high or too low. Having the patient’s arm held above the level of the heart is one part of the correct technique. (Refer to Table 9-5, Common Errors in Blood Pressure Measurement.)

Question 54

2.What is the pulse pressure for a patient whose blood pressure is 158/96 mm Hg and whose pulse rate is 72 beats per minute?

Answer 54

ANS: 62
The pulse pressure is the difference between the systolic and diastolic and reflects the stroke volume. The pulse rate is not necessary for pulse pressure calculations