The nurse is performing a general survey. Which action is a component of the general survey?
a.
Observing the patients body stature and nutritional
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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
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
A patients 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
B
A patients 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
A
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
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
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 [Show Less]