Chapter 9 Practice Questions Flashcards
The nurse is performing a general survey. Which action is a component of the general survey?
a. Observing the patients body stature and nutritional status
b. Interpreting the subjective information the patient has reported
c. Measuring the patients temperature, pulse, respirations, and blood pressure
d. Observing specific body systems while performing the physical assessment
a. Observing the patients body stature and nutritional status
When measuring a patients 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.
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.
d. Attempts should be made to weigh the patient at approximately the same time of day, if a sequence of weights is necessary.
During an examination of a child, the nurse considers that physical growth is the best index of a childs:
a. General health.
b. Genetic makeup.
c. Nutritional status.
d. Activity and exercise patterns.
a. General health.
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.
b. Consider these findings normal for a 1-month-old infant.
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
c. Presence of kyphosis and flexion in the knees and hips
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
c. Comatose adult
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 infants 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
d. Measuring the head circumference by wrapping the tape measure over the nose and cheekbones
c. Measuring the chest circumference at the nipple line with a tape measure
The nurse knows that one advantage of the tympanic membrane thermometer (TMT) is that:
a. Rapid measurement is useful for uncooperative younger children.
b. Using the TMT is the most accurate method for measuring body temperature in newborn 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.
a. Rapid measurement is useful for uncooperative younger children.
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
b. Radiation
When measuring a patients body temperature, the nurse keeps in mind that body temperature is influenced by:
a. Constipation.
b. Patients emotional state.
c. Diurnal cycle.
d. Nocturnal cycle.
c. Diurnal cycle.
When evaluating the temperature of older adults, the nurse should remember which aspect about an older adults body temperature?
a. The body temperature of the older adult is lower than that of a younger adult.
b. An older adults body temperature is approximately the same as that of a young child.
c. Body temperature depends on the type of thermometer used.
d. In the older adult, the body temperature varies widely because of less effective heat control
mechanisms.
a. The body temperature of the older adult is lower than that of a younger adult.
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.
c. Unexplained weight loss often accompanies short-term illnesses.
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.
d. Recognize that a tripod position is often used when a patient is having respiratory difficulties.
d. Recognize that a tripod position is often used when a patient is having respiratory difficulties.
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.
d. Shake the mercury-in-glass thermometer down to below 36.6 C before taking the temperature.
b. Leave the thermometer in place 3 to 4 minutes if the patient is afebrile.
The nurse is taking temperatures in a clinic with a TMT. Which statement istrue 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.
c. The risk of cross-contamination is reduced, compared with the rectal route.
