Question 1

Mary Jane is getting a physical examination prior to starting her new job. You take her vital signs: temperature (97.8°F), radial pulse 92 reg, + 2 amplitude, respiratory rate (20), and blood pressure 150/96. What is the category of Mary's blood pressure?

Accepted Answer

Mary's blood pressure is 150/96, which is in the Stage 1 Hypertension category.

Question 2

An 88-year-old patient had a warm sponge bath 10 minutes ago and a cup of hot tea 5 minutes ago. The nurse needs to assess her body temperature. Which temperature method should the nurse use to assess her temperature?

Accepted Answer

The tympanic method is the most appropriate choice in this scenario because it measures the temperature inside the ear, which is less likely to be affected by external factors such as having a warm sponge bath or drinking hot tea. Oral temperature could be artificially elevated due to the hot tea, and axillary temperature might be influenced by the recent bath. Rectal temperature is generally accurate but can be uncomfortable and less practical for routine checks in an elderly patient.

Question 3

You are performing a respiratory assessment on a male patient who has smoked for the past 30 years. You are having difficulty counting his respirations. Which of the following actions would be most appropriate?

Accepted Answer

Placing the diaphragm of the stethoscope over the trachea allows for better auscultation of respirations in patients with difficulty breathing.

Question 4

You are performing the general survey as part of the physical assessment. Which of the following observations are considered part of the general survey? Select all that apply.

Accepted Answer

These observations are all part of the general survey, which is a quick assessment of the patient's overall appearance, hygiene, vital signs, and apparent age and health.

Question 5

Normal vital signs change with age, sex, weight, exercise tolerance, and medical condition. Which of the following are classified as vital signs? Select all that apply.

Accepted Answer

Pulse, temperature, heart rate, and respiratory rate are all classified as vital signs because they are basic physiological metrics used to monitor a person's immediate health status. Weight, while important, is not considered a vital sign.

Question 6

Measuring a patient's body temperature is part of routine essential nursing care and can be taken in several different ways. The site and measuring device is chosen based on a number of factors including which of the following? Select all that apply.

Accepted Answer

The choice of site and measuring device for taking a patient's temperature depends on factors such as the patient's age, mental status, physical condition, and safety considerations, as well as the nurse's proficiency with the device. Patient preference is generally not a primary factor.

Question 7

Rectal temperatures are considered to be an accurate route for measuring core temperature. Rectal temperatures are contraindicated in which of the following patients? Select all that apply.

Accepted Answer

The answer of Rectal temperatures are considered to be an...

Question 8

A nurse is assessing a radial pulse. What characteristics of the pulse must be documented? Select all that apply.

Accepted Answer

The answer of A nurse is assessing a radial pulse....

Question 9

During a health assessment of a patient, a nurse is assessing vital signs, including respiratory rate. She knows that several factors can influence the respiratory rate including which of the following? Select all that apply.

Accepted Answer

All listed factors can influence respiratory rate. Exercise increases it due to higher oxygen demand. Medications can either increase or decrease it depending on their action. Pain and stress can elevate respiratory rate due to the body's stress response. Fever increases metabolic rate, thus increasing respiratory rate.

Question 10

A nurse is performing a vital sign assessment on a patient and understands that he must observe the following characteristics to assess a patient's breathing. Select all that apply.

Accepted Answer

Rate, depth, rhythm, and effort are all characteristics that a nurse observes to assess a patient's breathing. Skin movement is not a standard characteristic for assessing breathing.

Question 11

Hypertension is a growing health problem in the United States. The main factors that contribute to the increase in the number of patients with hypertension include which of the following? Select all that apply.

Accepted Answer

The obesity epidemic contributes to hypertension due to increased body weight. Population growth increases the number of individuals at risk. The aging population is more prone to hypertension due to physiological changes with age.

Question 12

High blood pressure is a modifiable risk factor for heart disease and stroke. Nurses are responsible for educating patients about lifestyle modifications for high blood pressure, which include which of the following? Select all that apply.

Accepted Answer

Reducing sodium, saturated fats, and cholesterol (A), quitting cigarette smoking (B), limiting alcohol intake (C), and losing weight if overweight (E) are all lifestyle modifications that can help manage high blood pressure. Genetic testing (D) is not a lifestyle modification for managing high blood pressure.

Question 13

A patient arrives for a health assessment and has poor hygiene, body odor, and clothes that are too big and unkempt. The nurse is concerned and considers which of the following reasons for the patient's condition? Select all that apply.

Accepted Answer

The patient's poor hygiene and unkempt appearance could be due to a lack of resources (A), impaired mental status or cognitive dysfunction (C), or lack of finances (D), which can all affect their ability to maintain personal hygiene and obtain appropriate clothing. Frugality (B) and a dislike for shopping (E) are less likely to be the primary reasons for such a condition.

Question 14

You are assessing a 60-year-old patient's blood pressure. You hear the systolic reading at 164. The Korotkoff sounds fade out at 130 and resume at 108. You hear the last Korotkoff sound at 82. This fading of sounds is called a[n] ________________ ________________.

Accepted Answer

The answer of You are assessing a 60-year-old patient's blood...

Question 15

You are preparing to assess the blood pressure. You start by wrapping the deflated cuff around the patient's arm about ___________ inch(es) above the brachial artery.

Accepted Answer

The answer of You are preparing to assess the blood...

Question 16

You are assessing the radial pulse and determine that it is 92 and irregular. You auscultate the apical pulse at 104 and irregular. What is the pulse deficit? ___________

Accepted Answer

The answer of You are assessing the radial pulse and...

Question 17

A normal resting pulse for a well-conditioned athlete is __________ to __________ beats per minute.

Accepted Answer

The answer of A normal resting pulse for a well-conditioned...

Question 18

Normal respirations are ________ to _________ breaths per minute.

Accepted Answer

The answer of Normal respirations are ________ to _________ breaths...

Question 19

In a normotensive (normal BP) blood pressure reading, the systolic reading is less than _________ and the diastolic reading is less than __________.

Accepted Answer

The answer of In a normotensive (normal BP) blood pressure...

Question 20

Hypertension is blood pressure reading greater than _________ or the diastolic reading greater than ________.

Accepted Answer

The answer of Hypertension is blood pressure reading greater than...

Quiz 6: General Survey and Assessing Vital Signs

Mary Jane is getting a physical examination prior to starting her new job. You take her vital signs: temperature (97.8°F) , radial pulse 92 reg, + 2 amplitude, respiratory rate (20) , and blood pressure 150/96. What is the category of Mary's blood pressure?