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. - ANSWERS-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 - ANSWERS-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 - ANSWERS-C
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 -
ANSWERS-C
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. - ANSWERS-A
When assessing an older adult, which vital sign changes occur with aging?
A Increase in pulse rate
B Widened pulse pressure
C Increase in body temperature
d Decrease in diastolic blood pressure - ANSWERS-B
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 - ANSWERS-B
,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. - ANSWERS-C
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. - ANSWERS-A
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. - ANSWERS-C
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. - ANSWERS-D
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. - ANSWERS-B
1. For which of the following patients would a comprehensive health history be appropriate?
A) A new patient with the chief complaint of "I sprained my ankle"
B) An established patient with the chief complaint of "I have an upper respiratory infection"
C) A new patient with the chief complaint of "I am here to establish care"
D) A new patient with the chief complaint of "I cut my hand" - ANSWERS-C
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