Chapter 9: General Survey, Measurement, and Vital Signs

Question 1

When performing a general survey, the examiner is:

a. observing the patient’s overall body structure and mobility.
b. interpreting the subjective information the patient has provided.
c. measuring the patient’s temperature, pulse, respirations, and blood pressure.
d. observing specific body systems while performing the physical assessment.

Answer 1

a.

Question 2

When measuring a patient’s weight, which of the following does the examiner keep in mind?

a. The patient should always be weighed with only his or her undergarments on.
b. It does not matter what type of scale is used, as long as the weights remain constant every day.
c. The patient may be allowed to wear his or her jacket and shoes while being weighed as long as this is recorded next to the weight.
d. Try to weigh the patient around the same time every day when a series of weights has to be taken.

Answer 2

d.

Question 3

A patient’s weekly blood pressure readings over 2 months have ranged between 124/84 and 136/88 mm Hg, with an average reading of 126/86 mm Hg. Within which blood pressure category does this blood pressure fall?

a. Normal blood pressure
b. Prehypertension
c. Stage I hypertension
d. Stage 2 hypertension

Answer 3

b.

Question 4

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

a.

Question 5

A 1-month-old infant has a head circumference of 34 cm and a chest circumference of 32 cm. 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 bring the infant back in 2 weeks to re-evaluate the head and chest circumferences.

Answer 5

b.

Question 6

When assessing an 80-year-old male patient, which of the following 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

Answer 6

c.

Question 7

In which of the following patients should the nurse measure rectal temperatures?

a. A school-age child
b. An older adult
c. A comatose adult
d. A patient who is receiving oxygen through a nasal cannula

Answer 7

c.

Question 8

The nurse is preparing to measure the length, weight, and chest and head circumferences of a 6-month-old infant. The nurse would measure the infant’s:

a. length by using a tape measure.
b. weight by placing the infant on an electronic standing scale.
c. chest circumference at the nipple line with a tape measure.
d. head circumference by wrapping the tape measure over the infant’s nose and cheekbones.

Answer 8

c.

Question 9

The nurse knows that one advantage of the tympanic thermometer is that:

a. the rapid measuring is useful in 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.

Answer 9

a.

Question 10

When assessing an older adult, which of the following vital sign changes should be considered to occur with aging?

a. An increase in pulse rate
b. A widened pulse pressure
c. An increase in body temperature
d. A decrease in diastolic blood pressure

Answer 10

b.

Question 11

Cellular metabolism requires a stable core temperature that is achieved by a balance between heat production and heat loss. Which of the following is a mechanism of heat loss in the body?

a. Exercise
b. Radiation
c. Metabolism
d. Food digestion

Answer 11

b.

Question 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. the diurnal cycle.
d. the nocturnal cycle.

Answer 12

c.

Question 13

When measuring the temperature of older adults, the nurse remembers that an older adult’s body temperature:

a. is lower than that of a younger adult.
b. is about the same as that of a young child.
c. depends on the type of thermometer used.
d. varies widely because of less effective heat control mechanisms.

Answer 13

a.

Question 14

A 60-year-old male patient has been treated for pneumonia for the past 6 weeks. He is in the clinic to check an “unexplained” weight loss of 4.5 kg (10 lb.) over the last 6 weeks. The nurse knows that:

a. his weight loss is probably from unhealthy eating habits.
b. chronic diseases such as hypertension don’t cause weight loss.
c. unexplained weight loss often accompanies short-term illnesses.
d. his weight loss is probably not the result of a mental dysfunction.

Answer 14

c.

Question 15

When assessing a 75-year-old patient with asthma, the nurse notes that he assumes the tripod position, leaning forward with arms braced on the chair. On the basis of this observation, the nurse would:

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.
d. recognize that the tripod position is often used when a patient is experiencing respiratory difficulties.

Answer 15

d.

Question 16

Which of the following describes the correct technique the nurse should use when measuring oral temperature with a mercury thermometer?

a. Wait for 30 minutes if the patient has ingested hot or cold liquids.
b. Leave the thermometer in place for 3 to 4 minutes if the patient is afebrile.
c. Place the thermometer in front of the tongue and have the patient close his or her lips.
d. Shake the mercury-in-glass thermometer down to 36.6°C (98°F) before taking the temperature.

Answer 16

b.

Question 17

Which of the following statements about use of the tympanic thermometer is true?

a. Taking a tympanic temperature is more time consuming than taking a rectal temperature.
b. The tympanic method is more invasive and uncomfortable than the oral method.
c. With the tympanic method, there is reduced risk of cross-contamination compared with the rectal route.
d. The tympanic membrane most accurately reflects the temperature in the ophthalmic artery.

Answer 17

c.

Question 18

To accurately measure the rectal temperature in an adult, the nurse would:

a. use a lubricated blunt-tip thermometer.
b. insert the thermometer 5 to 7.5 cm (2 to 3 in) into the rectum.
c. leave the thermometer in place for up to 8 minutes if the patient is febrile.
d. wait for 2 to 3 minutes if the patient has recently smoked a cigarette.

Answer 18

a.

Question 19

When measuring the radial pulse of a patient, the nurse should count the pulse:

a. for 1 minute if the rhythm is irregular.
b. for 15 seconds and multiply by four, if the rhythm is regular.
c. initially for a full 2 minutes to detect any variation in amplitude.
d. for 10 seconds and multiply by six, if the patient has no history of cardiac abnormalities.

Answer 19

a.

Question 20

When assessing a patient’s pulse, which of the following characteristics should the nurse note?

a. Force
b. Pallor
c. Capillary refill time
d. Timing in the cardiac cycle

Answer 20

a.

Question 21

When assessing the pulse of a 6-year-old boy, the nurse notes that his heart rate varies with his respiratory cycle, speeding up at the peak of inspiration and slowing to normal with expiration. The nurse would:

a. notify the physician immediately.
b. consider this a normal finding in children and young adults.
c. check the child’s blood pressure and note any variations in respiration.
d. document that this child has bradycardia and continue with the assessment.

Answer 21

b.

Question 22

Which of the following statements about the force, or strength, of the pulse is true?

a. It is usually recorded on a 0- to 2-point scale.
b. It demonstrates elasticity of the vessel wall.
c. It is a reflection of the heart’s stroke volume.
d. It reflects the blood volume in the arteries during diastole.

Answer 22

c.

Question 23

The nurse is assessing the vital signs of a 20-year-old marathon runner and documents the following vital signs: temperature—36°C (97°F); pulse—50 beats per minute; respirations—14/minute; blood pressure—104/68 mm Hg. Which of the following statements about these results is true?

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 today’s readings, the patient should return to the clinic in 1 week.

Answer 23

b.

Question 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. Count the respirations for a full minute, noting rate and rhythm.
b. Check the child’s pulse and respirations simultaneously for 30 seconds.
c. Check the child’s respirations for a minimum of 5 minutes to identify any variations in respiratory pattern.
d. Count the patient’s respirations for 15 seconds and multiply by four to obtain the number of respirations per minute.

Answer 24

a.

Question 25

A patient’s blood pressure is 118/82 mm Hg. He asks the nurse to explain “what the numbers mean.” The nurse’s best reply would be:

a. “The numbers are within normal range and 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 on the arteries when the heart contracts.”
d. “The concept of blood pressure is difficult to understand. The main thing to be concerned about is the top number, or systolic blood pressure.”

Answer 25

c.

Question 26

Which of the following factors helps determine blood pressure?

a. Pulse rate
b. Pulse pressure
c. Vascular output
d. Peripheral vascular resistance

Answer 26

d.

Question 27

A nurse is helping at a health fair at a local mall. When measuring blood pressures in a variety of people, the nurse keeps in mind that:

a. after menopause, blood pressure in women is usually lower than in men.
b. an adult of African descent often has a higher blood pressure than an adult of European descent who is the same age.
c. blood pressure measurements in overweight people should be the same as in those of normal weight.
d. a teen’s blood pressure reading will be lower than that of an adult.

Answer 27

b.

Question 28

The nurse notices that a colleague is about to check the blood pressure of an obese patient with 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

b.

Question 29

A student is late for his appointment and has rushed across campus to the health clinic. Before assessing his vital signs, the nurse should:

a. allow him time to relax and rest, for about 5 minutes, before checking his vital signs.
b. check the blood pressure in both arms, expecting a difference in the readings because of his recent exertion.
c. monitor his vital signs immediately on his arrival at the clinic, then 5 minutes later, and note any differences.
d. check his blood pressure in the supine position because this will give a more accurate reading and allow him to relax at the same time.

Answer 29

a.

Question 30

The nurse will perform palpation before auscultating for blood pressure. The reason for this is to:

a. hear the Korotkoff sounds more clearly.
b. detect the presence of an auscultatory gap.
c. avoid missing a falsely elevated blood pressure.
d. identify phase IV of the Korotkoff sounds more readily.

Answer 30

b.

Question 31

The nurse is taking the initial blood pressure on a 72-year-old patient with documented hypertension. How should the nurse proceed?

a. Place the cuff on the patient’s arm and inflate it 30 mm Hg above the patient’s pulse rate.
b. Inflate the cuff to 200 mm Hg in an attempt to obtain the most accurate systolic reading.
c. Inflate the blood pressure cuff 30 mm Hg above the point at which the palpated pulse disappears.
d. Consider the patient’s past blood pressure readings and inflate the cuff 30 mm Hg above the highest systolic reading recorded.

Answer 31

c.

Question 32

The nurse has collected the following information on a patient: palpated blood pressure—180; auscultated blood pressure—170/100 mm Hg; apical pulse—60; radial pulse—70. What is the patient’s pulse pressure?

Answer 32

b.

Question 33

When auscultating the blood pressure of a 25-year-old, the nurse finds that the phase I Korotkoff sounds begin at 200 mm Hg. At 100 mm Hg, the Korotkoff sounds become muffled, and at 92 mm Hg, they 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

a.

Question 34

A patient is at the clinic complaining of “fainting episodes that started last week.” How should the nurse proceed with the examination?

a. Take the blood pressure in both arms and thighs.
b. Assist the patient to a lying position and begin taking the blood pressure.
c. Record the blood pressure with the patient in the lying, sitting, and standing positions.
d. Record the blood pressure with the patient in the lying and sitting positions, and average these numbers to obtain a mean blood pressure.

Answer 34

c.

Question 35

A 70-year-old man has a blood pressure of 150/90 mm Hg in the lying position, 130/80 mm Hg in the sitting position, and 100/60 mm Hg in the standing position. How should the nurse evaluate these findings?

a. This is a normal response due to changes in the patient’s position.
b. The change in blood pressure readings indicates orthostatic hypotension.
c. The blood pressure reading in the lying position is within normal limits.
d. The change in blood pressure reading is considered within normal limits for the patient’s age.

Answer 35

b.

Question 36

Which of the following statements about thigh pressure is true?

a. Auscultate either the popliteal or femoral vessels to obtain thigh pressure.
b. The best patient position for measuring thigh pressure is the supine position with the knee slightly bent.
c. If the blood pressure in the arm is high in an adolescent, compare it with thigh pressure.
d. Thigh pressure is lower than that in the arm due to the distance from the heart and the size of the popliteal vessels.

Answer 36

c.

Question 37

The nurse is preparing to measure the vital signs of a 6-month-old infant. The nurse will:

a. measure respirations and then pulse and temperature.
b. measure vital signs more frequently than in an adult.
c. explain procedures and encourage the infant to handle the equipment.
d. allow the infant to become familiar with the nurse by performing the physical examination first and then measuring the vital signs.

Answer 37

a.

Question 38

A 4-month-old child is at the clinic for a well-baby checkup and immunizations. Which of the following actions is most appropriate when the nurse is assessing an infant’s vital signs?

a. Palpate the infant’s radial pulse and note any fluctuations resulting from activity or exercise.
b. Auscultate for an apical rate for 1 minute and assess for any normal irregularities such as sinus arrhythmia.
c. Assess the infant’s blood pressure by using a stethoscope with a large diaphragm piece to hear the soft muffled Korotkoff sounds.
d. Watch the infant’s chest, and count the respiratory rate for 1 minute because the respiratory pattern may vary significantly.

Answer 38

b.

Question 39

Which of the following statements about vital sign measurements in older adults is true?

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.
c. A decreased pulse pressure occurs from changes in systolic and diastolic blood pressures.
d. Changes in the body’s temperature regulatory mechanism leave the older adult more likely to develop a fever.

Answer 39

b.

Question 40

In a patient with acromegaly, the nurse will expect to observe:

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 40

c.

Question 41

The nurse is performing a general survey on a patient. Which of the following findings 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 height.

Answer 41

d.

Question 42

Which of the following statements about measurement of blood pressure in children is true?

a. The blood pressure guidelines for children are based on age.
b. Phase II Korotkoff sounds are the best indicator of systolic blood pressure in children.
c. Use of Doppler device is recommended for accurate blood pressure measurement in children until adolescence.
d. The disappearance of phase V Korotkoff can be used for the diastolic reading in children and adults.

Answer 42

d.

Question 43

What type of blood pressure measurement error is most likely to occur if the examiner does not check for the presence of an auscultatory gap?

a. The diastolic blood pressure may not be heard.
b. The diastolic blood pressure may be falsely low.
c. The systolic blood pressure may be falsely low.
d. The systolic blood pressure may be falsely high.

Answer 43

c.

Question 44

Which of the following best describes mean arterial pressure (MAP)?

a. It is the pressure of the arterial pulse.
b. It reflects the stroke volume of the heart.
c. It is the pressure forcing blood into the tissues, averaged over the cardiac cycle.
d. It is an average of the systolic and diastolic blood pressures and reflects tissue perfusion.

Answer 44

c.

Question 45

A 75-year-old man has a history of hypertension and was recently changed to a new antihypertensive drug. He reports feeling dizzy at times. How should the nurse evaluate his blood pressure?

a. Assess blood pressure and pulse with the patient in the supine, sitting, and standing positions.
b. Have him walk around the room, and assess his blood pressure after the activity.
c. Assess blood pressure and pulse at the beginning as well as at the end of the examination.
d. Take the blood pressure on the right arm and then 5 minutes later on the left arm.

Answer 45

a.

Question 46

Which of the following 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 46

b.

Question 47

Which of the following statements about taking an axillary temperature is true?

a. A stable axillary temperature will register after 3 minutes.
b. The accuracy and reliability of this method are well established.
c. Its results are closer to the core temperature than the inguinal method.
d. The axillary method is safer and more accessible than the rectal method.

Answer 47

d.

Question 48

When counting an infant’s respirations, the nurse will:

a. watch the chest rise and fall.
b. watch the abdomen for movement.
c. place a hand across the infant’s chest.
d. use a stethoscope to listen to breath sounds.

Answer 48

b.

Question 49

Which of the following is true about checking for proper blood pressure cuff size?

a. The standard cuff size is appropriate for all persons.
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 49

d.

Question 50

During an examination, the nurse notes that a female patient has a round “moon” face, central trunk obesity, and a cervical hump. Her skin is fragile and has bruises. Which of the following conditions does the nurse note in this patient?

a. Marfan syndrome
b. Gigantism
c. Cushing’s syndrome
d. Acromegaly

Answer 50

c.