Quizlet 1 - practice questions PDF

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Sherpath Study online at quizlet.com/_3npj6w 1.

After monitoring the actions of a student nurse who is measuring a patient's blood pressure, the nurse concludes that all observations were correctly documented except the diastolic blood pressure. What action by the student nurse would have created an error in this step? The student nurse places the patient's hand at heart level.

the student nurse pauses during descent and inflates the cuff

4.

auscultation

includes listening to sounds produced by the body. A stethoscope is used to identify characteristics of sounds, which include intensity, duration, pitch, and quality.

5.

blunt or fist percussion

Expose the patient's skin. Place the nondominant hand on the body and strike with the fist of the dominant hand. -elicit tenderness arising from the liver, gallbladder, or kidneys.

6.

During a health assessment the nurse records a patient's body mass index (BMI) at 37. What does the nurse infer from this finding?

the patient has class 2 obesity

The student nurse pauses during descent and reinflates the cuff. The student nurse presses softly on the stethoscope on the brachial artery. The student nurse measures the blood pressure while the patient's feet are flat on the floor. 2.

After performing physical exams on a group of elderly patients at a community center, the nurse finds that several of the patients are shorter than they were 10 years ago. What are possible explanations for this finding?

Slight flexion in the in knees and hips

Shortening of the long bones

Shortening of the individual vertebrae

Postural changes of kyphosis

The patient is overweight. The patient has class 1 obesity. The patient has class 2 obesity.

Thickening of the vertebral disks

Shortening of the individual vertebrae

slight flexion in the knees and hips

At a community health fair, the nurse prepares to assess the blood pressure of a patient who is sitting in a chair by using the patient's bare right arm supported at heart level. What is the priority nursing intervention before beginning the blood pressure assessment?

Check that the patient's feet are flat on the floor.

Slight flexion in the in knees and hips

3.

Place the bladder balloon out of the wrap. Inflate the cuff to the maximum inflation level. Check that the patient's feet are flat on the floor. Check that the arm of the patient is above heart level.

The patient has class 3 obesity. 7.

During a public health fair, the nurse measures the oral temperature of a patient and then learns the patient just drank a cup of iced coffee. Which action by the nurse is most appropriate? Instructing the patient to drink warm water before reassessing. Instructing the patient to rinse with a mouthwash and reassess. Measure the patient's temperature 15 minutes after drinking the cold liquid. Measure the patient's temperature 2 minutes after drinking the cold liquid.

Measure the patient's temperature 15 minutes after drinking the cold liquid.

8.

During a vital sign assessment of an adult patient, the nurse observes that the rectal temperature is 99.3° F (37.4° C). What should the nurse conclude from the finding?

normal body temp

13.

The patient is running a fever. The patient has normal body temperature. The patient is suffering from hypothermia.

9.

The four basic techniques of the physical examination are

(1) inspection, (2) palpation, (3) percussion, and (4) auscultation.

10.

general inspection

observing the patient from front to back and from each side, checking for symmetry of body parts, obvious injuries or abnormalities, and overall appearance.

12.

guidelines for inspection include

Guidelines for palpation include

decrease the oxygen requirement of the body

Increase in the immunity of the patient

The thermometer is giving a false reading. Eugene on target

11.

The health care provider asks the nurse to purposefully induce hypothermia in a patient who is in the post-cardiac arrest period. What is the reason for this intervention?

-having adequate sunlight or artificial light -conducting an unhurried, and careful inspection -exposing what needs inspection -validating findings with patient -ensuring appropriate equipment is available -Keep fingernails short to avoid hurting the patient -Have warm hands and be gentle in approach to assist the patient in relaxing in order to obtain more accurate data -Use correct palpation depth and the appropriate part of the hand to correctly identify findings without producing unnecessary discomfort to the patient

Increase in the heart rate of the patient Decrease in blood clotting time in the patient Decrease in the oxygen requirement of the body 14.

immediate (direct ) percussion

Expose the patient's skin. Then strike the finger directly against the patient's body using short, sharp strokes of the fist or fingertips. -back use fist -sinuses use finger tips

15.

inspection

involves looking at the patient to gather information. Inspection includes general inspection and systematic inspection

16.

Inspection has two parts

general and systematic inspection

17.

mediate (indirect ) percusssion

Expose the patient's skin. Use the middle finger of the dominant hand as a hammer; the middle finger of the nondominant hand is placed on the body and is struck by the dominant finger. Keep the other fingers fanned out and not touching the skin to avoid dulling the sound. Snap the wrist of the dominant hand downward and then strike the middle finger of the nondominant hand to produce a tone. -thorax and abdomen

18.

The nurse auscultates to obtain which assessment information?

Sounds produced by internal organs Auscultation involves listening to sounds produced by internal organs.

21.

The nurse is assessing a patient's blood pressure. Which type of Korotkoff sound does the nurse correlate with the systolic blood pressure?

tapping noise

Tapping sounds Muffled sounds

The sound of heart valves closing Auscultation is used to identify the activity of the heart, such as heart valves closing.

Knocking sounds Swooshing sounds 22.

Expected movement of air or fluid through internal organs Auscultation involves listening to sounds caused by expected movement of air or fluid through internal organs. 19.

The nurse avoids using the averagegive false high sized cuff while measuring the blood blood pressure pressure of a 20-year-old patient who reading has cone-shaped, obese arms. What is the rationale behind avoiding the average-sized cuff?

The systolic pressure difference is 5 mm Hg between phases IV and V.

The systolic pressure difference is 10 mm Hg between phases IV and V. The diastolic pressure difference is 10 mm Hg between phases IV and V. 23.

The neonate has dyspnea.

It is a type of tapered cuff that is not suitable for obese adults.

The nurse finds that the pulse rate of 15 breaths/min a healthy individual is 60 beats/minute during the assessment. What breaths to beats is respiratory rate does the nurse expect usually 1:4 in the individual? Record your answer using a whole number.

The nurse is assessing the respiratory rate the neonate of a neonate every minute for the past 20 has dyspnea minutes and finds that, on average, the neonate breathes 24 times a minute. What does the nurse conclude from the findings? The neonate has apnea.

It gives a false high blood pressure reading.

20.

The diastolic pressure difference is 10 mm Hg between phases IV and V.

The diastolic pressure difference is 5 mm Hg between phases IV and V.

It is not appropriate for this age.

Its rubber bladder width is more than 40% of arm circumference.

The nurse is assessing a pregnant woman's blood pressure. After assessment, the nurse documents the blood pressure as 140/96/80. What does this reading indicate?

The neonate has tachypnea. The neonate has normal respiration. 24.

The nurse is calculating the body mass index (BMI) of a patient weighing approximately 135 lbs. The nurse records the patient's height at 62 inches. What BMI value does the nurse enter in the records after calculation? Round to the nearest whole number.

26 BMI BMI = weight in pounds/(height in inches) 2 × 703.

25.

The nurse is caring for a child with brain temporal artery trauma. Which is the best thermometer to probe measure the temperature within 6 seconds?

29.

The nurse is caring for a patient who has had dysarthria a cerebrovascular accident. The nurse and observes that the patient has difficulty hyperthermia swallowing foods. Which other findings is the nurse likely to observe in this patient?

Temporal artery thermometer Diarrhea Tympanic membrane thermometer Dysarthria Electronic thermometer with red-tipped probe

Hyperthermia

Electronic thermometer with blue-tipped probe 26.

27.

Hyperglycemia

The nurse is caring for a geriatric patient who has a fever. The nurse records the patient's oral temperature at 37.5° C. What will this patient's rectal temperature be? Record your answer using a whole number.

38 degrees celcius

The nurse is caring for a patient who has a big head with a receding hairline. On further assessment, the nurse finds that the patient has an increased curvature of the thoracic spine and an inward curvature of the lumbar spine. Which medical condition do these findings suggest?

achondroplastic dwarfism

Hypocalcemia 30.

The nurse is caring for a patient with an acute myocardial infarction. What does the nurse expect to find in the patient? Depression Hypotension Hypohidrosis Cool, clammy skin Shoulder and jaw pain

31.

Marfan syndrome Cushing syndrome

The nurse is caring for four patients in a hospital setting. Which patient does the nurse expect to have a pubis-to-sole measurement greater than the crown-topubis measurement?

Hypopituitary dwarfism Achondroplastic dwarfism 28.

The nurse is caring for a patient who has acromegaly. Which findings does the nurse expect to find in the patient's laboratory reports? Decreased blood calcium levels Increased growth hormone levels Decreased blood pressure in the patient Increased blood sugar levels in the patient Decreased serum alkaline phosphatase levels

hypotension cool,clammy skin shoulder and jaw pain

increased growth hormone levels and increased blood sugar levels

Patient A: has infantile facial features and chubbiness Patient B: large head bossing, and an enlarged heart Patient C: narrow face, long thin fingers, and flat feet Patient D: moonlike face and thin arms and legs

patient C

32.

The nurse is conducting a clinical interview for a patient who reports dyspnea. After asking the patient to sit in a chair and slowly exhale, the nurse suspects that the patent is at risk of chronic pulmonary disease. Which finding would support the nurse's suspicion? The patient sits on the chair with arms relaxed at sides.

The patient leans forward with arms braced on the arms of the chair.

35.

It should be measured only in infants. It can be only measured in the prone position. Diastolic pressure is 10 to 40 mm Hg higher in the thigh than in the arm.

The patient curls up in the fetal position, while sitting in the chair.

36.

The patient leans forward with arms braced on the arms of the chair. The nurse is conducting a physical examination of a patient who is tall with a narrow face and flat feet. The nurse finds that the arm span of the patient is greater than the height. What does the nurse infer from these findings?

it is higher than in the arm

It is higher than in the arm.

The patient sits upright in the chair and resists lying down.

33.

The nurse is measuring a patient's thigh blood pressure (BP). What is the most important point that the nurse should remember about thigh pressure?

marfan syndrome

A nurse is meeting with the parents of a 10year-old child who was recently diagnosed with cerebral palsy. What suggestion does the nurse give to the child's parents to help the child dress more easily?

"Select clothes with Velcro fasteners for the child."

"Select clothes with buttons for the child." "Select loose-fitting clothes for the child." "Select clothes with long sleeves for the child."

The patient has gigantism. The patient has acromegaly.

"Select clothes with Velcro fasteners for the child."

The patient has Marfan syndrome. 37.

The patient has Cushing syndrome. 34.

The nurse is leading a parent education session on general health checks. One parent asks about the correct age to start routine blood pressure (BP) measurement in children. Which answer by the nurse is most appropriate?

3 years

The nurse is performing a behavioral assessment on a patient. Which sign indicates that the patient is suffering from depression?

unkempt appearance along with body odor

Clean-shaven face Bags under the eyes Even-patterned speech

1 year Unkempt appearance along with body odor 3 years 4 years 7 years

38.

The nurse is performing a physical full and assessment of a patient who is having an bounding anxiety attack. What type of pulse should the nurse expect to find in the patient? Normal Full and bounding Weak and thready Absent

39.

The nurse is reviewing the laboratory reports of a patient with Cushing syndrome. What finding does the nurse observe in this patient's reports?

hypercortisolism

43.

The nurse measures the body mass index (BMI) of a patient at 34, but concludes that the measurement is not a reliable method to accurately assess the patient's body fat. Why did the nurse make this conclusion?

the patient is highly muscular

Hypoglycemia The patient has dyslipidemia. Hypercalcemia The patient is highly muscular. Hypopituitarism The patient has abdominal ascites. Hypercortisolism 40.

41.

the nurse is taking a rectal temperature of a patient. What are the precautions that the nurse should take to ensure the safety of the patient? wear a pair of gloves use a lubricant insert only 2-3 cm deep leave the temperature probe in the rectum leave the thermometer inside for 5 mins

use a lubricant insert only 2-3 cm deep

The nurse is teaching a group of caretakers about the proper use of an oral thermometer. Which statement by a caregiver indicates effective learning?

"Drinking hot liquids may alter the temperature reading."

The patient has a large waist circumference. 44.

To prevent stimulation of the sympathetic nervous system To prevent additional pressure of gravity on the brachial artery To prevent sustained isometric muscular contraction in the patient

"The normal Celsius temperature for an adult is 38.3°."

A nursing instructor is lecturing on pulse oximetry. Which statement by a student indicates the need for further teaching?

"Drinking hot liquids may alter the temperature reading."

"A healthy person without lung disease will have a value less than 95%."

"A glass thermometer should be placed in front of the tongue."

"The instrument compares the ratio of light emitted with light absorbed."

45.

The nurse is treating a patient who is acute curling over in the fetal position while abdominal pain sitting on the exam chair. What is the first thing the nurse should assess for in this patient? Osteoarthritis Acute abdominal pain Congestive heart failure Chronic pulmonary disease

To eliminate the effect of hydrostatic pressure

To eliminate the effect of hydrostatic pressure

"Oral temperature is higher than rectal temperature."

42.

The nurse places the patient's arm at the level of the heart when measuring the blood pressure. What is the reason for this nursing intervention?

"The pulse reading on the instrument must match the palpated pulse." "At lower oxygen saturations, the earlobe probe is more accurate."

"A healthy person without lung disease will have a value less than 95%."

46.

A nursing instructor is teaching students about cuff sizes. Which statement by the student indicates effective learning about cuff sizes?

"A narrow cuff size will give a false high blood pressure (BP)."

"A narrow cuff size will give a false high blood pressure (BP)." "There is one standard or universal size of cuff." "Cuff size should be determined as per the age of the patient." "Cuffs are not available for the measurement of thigh pressure." 47.

palpation

involves using appropriate areas of the hand to elicit findings. Palpation uses touch to gather information related to texture, shape, pulsations, temperature, and moisture

48.

palpation with back or hand

temperature and moisture

49.

palpation with ball of hand

vibrations or thrills

50.

palpation with finger pads

51.

palpation with forefinger and thumb

52.

palpation with whole hand

53.

A patient has increased blood pressure. Which factors could be responsible for this finding in the patient? Increased blood volume Decreased cardiac output Decreased blood viscosity Increased vasoconstriction Increased elasticity of vessel walls

54.

percussion

uses sound waves to gather information about the density of tissue. Percussion can be direct or indirect and is used to evaluate the size and borders of internal organs. Percussion can also provide information about tenderness or the amount of fluid within a body cavity.

55.

percussion

includes listening for varying tones produced by body cavities or organs. Percussion can be immediate (direct), mediate (indirect), or blunt (fist)

56.

percussion over emphysemic lungs

...

57.

percussion over muscle

flat, soft and high. very dull

58.

percussion over stomach

tympanic high, loud, drumlike

59.

percussion principles

-One object striking against another object produces vibrations and sound waves. -The tapping of the nurse's finger causes vibrations by impact on underlying tissues. -Sound waves arise from vibrations and produce percussion tones. -The tone heard is related to density of underlying tissue.

60.

percussion tone over healthy lungs

resonant: loud, low,long hollow

61.

percussion tone over liver

dull: thudlike

62.

Sys...