Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Grad, Exams of Nursing

Download Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Grad and more Exams Nursing in PDF only on Docsity! Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Chapter 08: 1. When performing a physical assessment, the first technique the nurse will always use is: a. Palpation. b. Inspection. c. Percussion. d. Auscultation. B The skills requisite for the physical examination are inspection, palpation, percussion, and auscultation. The skills are performed one at a time and in this order (with the exception of the abdominal assessment, during which auscultation takes place before palpation and percussion). The assessment of each body system begins with inspection. A focused inspection takes time and yields a surprising amount of information. 2. The nurse is preparing to perform a physical assessment. Which statement is true about the physical assessment? The inspection phase: a. Usually yields little information. b. Takes time and reveals a surprising amount of information. c. May be somewhat uncomfortable for the expert practitioner. d. Requires a quick glance at the patient’s body systems before Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS proceeding with palpation. B A focused inspection takes time and yields a surprising amount of information. Initially, the examiner may feel uncomfortable, staring at the person without also doing something. A focused assessment is significantly more than a “quick glance.” 3. The nurse is assessing a patient’s skin during an office visit. What part of the hand and technique should be used to best assess the patient’s skin temperature? a. Fingertips; they are more sensitive to small changes in temperature. b. Dorsal surface of the hand; the skin is thinner on this surface than on the palms. c. Ulnar portion of the hand; increased blood supply in this area enhances temperature sensitivity. d. Palmar surface of the hand; this surface is the most sensitive to temperature variations because of its increased nerve supply in this area. B The dorsa (backs) of the hands and fingers are best for determining temperature because the skin is thinner on the dorsal surfaces than on the palms. Fingertips are best for fine, tactile discrimination. The other Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS C Percussion yields a sound that depicts the location, size, and density of the underlying organ. Turgor and texture are assessed with palpation. 8. The nurse is reviewing percussion techniques with a newly graduated nurse. Which technique, if used by the new nurse, indicates that more review is needed? a. Percussing once over each area b. Quickly lifting the striking finger after each stroke c. Striking with the fingertip, not the finger pad d. Using the wrist to make the strikes, not the arm A For percussion, the nurse should percuss two times over each location. The striking finger should be quickly lifted because a resting finger damps off vibrations. The tip of the striking finger should make contact, not the pad of the finger. The wrist must be relaxed and is used to make the strikes, not the arm. 9. When percussing over the liver of a patient, the nurse notices a dull sound. The nurse should: a. Consider this a normal finding. b. Palpate this area for an underlying mass. c. Reposition the hands, and attempt to Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS percuss in this area again. d. Consider this finding as abnormal, and refer the patient for additional treatment. A Percussion over relatively dense organs, such as the liver or spleen, will produce a dull sound. The other responses are not correct. 10. The nurse is unable to identify any changes in sound when percussing over the abdomen of an obese patient. What should the nurse do next? a. Ask the patient to take deep breaths to relax the abdominal musculature. b. Consider this finding as normal, and proceed with the abdominal assessment. c. Increase the amount of strength used when attempting to percuss over the abdomen. d. Decrease the amount of strength used when attempting to percuss over the abdomen. C The thickness of the person’s body wall will be a factor. The nurse needs a stronger percussion stroke for persons with obese or very muscular body walls. The force of the blow determines the loudness of the note. The other actions are not correct. Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS 11. The nurse hears bilateral loud, long, and low tones when percussing over the lungs of a 4- year-old child. The nurse should: a. Palpate over the area for increased pain and tenderness. b. Ask the child to take shallow breaths, and percuss over the area again. c. Immediately refer the child because of an increased amount of air in the lungs. d. Consider this finding as normal for a child this age, and proceed with the examination. D Percussion notes that are loud in amplitude, low in pitch, of a booming quality, and long in duration are normal over a child’s lung. 12. A patient has suddenly developed shortness of breath and appears to be in significant respiratory distress. After calling the physician and placing the patient on oxygen, which of these actions is the best for the nurse to take when further assessing the patient? a. Count the patient’s respirations. b. Bilaterally percuss the thorax, noting any differences in percussion tones. c. Call for a chest x-ray study, and wait for the results before Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS b. Leave the gown on the patient to ensure that he or she does not get chilled during the examination. c. Ensure that the bell side of the stethoscope is turned to the “on” position. d. Check the temperature of the room, and offer blankets to the patient if he or she feels cold. D The examination room should be warm. If the patient shivers, then the involuntary muscle contractions can make it difficult to hear the underlying sounds. The end of the stethoscope should be warmed between the examiner’s hands, not with water. The nurse should never listen through a gown. The diaphragm of the stethoscope should be used to auscultate for bowel sounds. 16. The nurse will use which technique of assessment to determine the presence of crepitus, swelling, and pulsations? a. Palpation b. Inspection c. Percussion d. Auscultation A Palpation applies the sense of touch to assess texture, temperature, moisture, organ location and size, as well as any swelling, vibration or pulsation, rigidity or spasticity, crepitation, presence of lumps or masses, and the presence of tenderness or pain. Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS 17. The nurse is preparing to use an otoscope for an examination. Which statement is true regarding the otoscope? The otoscope: a. Is often used to direct light onto the sinuses. b. Uses a short, broad speculum to help visualize the ear. c. Is used to examine the structures of the internal ear. d. Directs light into the ear canal and onto the tympanic membrane. D The otoscope directs light into the ear canal and onto the tympanic membrane that divides the external and middle ear. A short, broad speculum is used to visualize the nares. 18. An examiner is using an ophthalmoscope to examine a patient’s eyes. The patient has astigmatism and is nearsighted. The use of which of these techniques would indicate that the examination is being correctly performed? a. Using the large full circle of light when assessing pupils that are not dilated b. Rotating the lens selector dial to the black numbers to compensate for Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS astigmatism c. Using the grid on the lens aperture dial to visualize the external structures of the eye d. Rotating the lens selector dial to bring the object into focus D The ophthalmoscope is used to examine the internal eye structures. It can compensate for nearsightedness or farsightedness, but it will not correct for astigmatism. The grid is used to assess size and location of lesions on the fundus. The large full spot of light is used to assess dilated pupils. Rotating the lens selector dial brings the object into focus. 19. The nurse is unable to palpate the right radial pulse on a patient. The best action would be to: a. Auscultate over the area with a fetoscope. b. Use a goniometer to measure the pulsations. c. Use a Doppler device to check for pulsations over the area. d. Check for the presence of pulsations with a stethoscope. C Doppler devices are used to augment pulse or blood pressure measurements. Goniometers measure joint range of motion. A fetoscope is used to Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS prevent the spread of bacteria from one part of the body to another. d. Gloves are worn throughout the entire examination to demonstrate to the patient concern regarding the spread of infectious diseases. B The nurse should wash his or her hands before and after every physical patient encounter; after contact with blood, body fluids, secretions, and excretions; after contact with any equipment contaminated with body fluids; and after removing gloves. Hands should be washed after gloves have been removed, even if the gloves appear to be intact. Gloves should be worn when potential contact with any body fluids is present. 23. The nurse is examining a patient’s lower leg and notices a draining ulceration. Which of these actions is most appropriate in this situation? a. Washing hands, and contacting the physician b. Continuing to examine the ulceration, and then washing hands c. Washing hands, putting on gloves, and continuing with the examination of the ulceration d. Washing hands, proceeding with rest of the physical examination, and then continuing with the examination of the leg ulceration Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS C The examiner should wear gloves when the potential contact with any body fluids is present. In this situation, the nurse should wash his or her hands, put on gloves, and continue examining the ulceration. 24. During the examination, offering some brief teaching about the patient’s body or the examiner’s findings is often appropriate. Which one of these statements by the nurse is most appropriate? a. “Your atrial dysrhythmias are under control.” b. “You have pitting edema and mild varicosities.” c. “Your pulse is 80 beats per minute, which is within the normal range.” d. “I’m using my stethoscope to listen for any crackles, wheezes, or rubs.” C The sharing of some information builds rapport, as long as the patient is able to understand the terminology. 25. The nurse keeps in mind that the most important reason to share information and to offer brief teaching while performing the physical examination is to help the: a. Examiner feel more comfortable and to gain control of the situation. b. Examiner to build rapport and to Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS increase the patient’s confidence in him or her. c. Patient understand his or her disease process and treatment modalities. d. Patient identify questions about his or her disease and the potential areas of patient education. B Sharing information builds rapport and increases the patient’s confidence in the examiner. It also gives the patient a little more control in a situation during which feeling completely helpless is often present. 26. The nurse is examining an infant and prepares to elicit the Moro reflex at which time during the examination? a. When the infant is sleeping b. At the end of the examination c. Before auscultation of the thorax d. Halfway through the examination B The Moro or startle reflex is elicited at the end of the examination because it may cause the infant to cry. 27. When preparing to perform a physical examination on an infant, the nurse should: Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS the child’s trust has been obtained. C The best place to examine the toddler is on the parent’s lap. Toddlers understand symbols; therefore, a security object is helpful. Initially, the focus is more on the parent, which allows the child to adjust gradually and to become familiar with you. A 2-year-old child does not like to take off his or her clothes. Therefore, ask the parent to undress one body part at a time. 30. The nurse is examining a 2-year-old child and asks, “May I listen to your heart now?” Which critique of the nurse’s technique is most accurate? a. Asking questions enhances the child’s autonomy b. Asking the child for permission helps develop a sense of trust c. This question is an appropriate statement because children at this age like to have choices d. Children at this age like to say, “No.” The examiner should not offer a choice when no choice is available D Children at this age like to say, “No.” Choices should not be offered when no choice is really available. If the child says, “No” and the nurse does it anyway, then the nurse loses trust. Autonomy is enhanced by offering a limited option, “Shall I listen to your heart next or your tummy?” 31. With which of these patients would it be most appropriate for the nurse to Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS use games during the assessment, such as having the patient “blow out” the light on the penlight? a. Infant b. Preschool child c. School-age child d. Adolescent B When assessing preschool children, using games or allowing them to play with the equipment to reduce their fears can be helpful. Such games are not appropriate for the other age groups. 32. The nurse is preparing to examine a 4-year-old child. Which action is appropriate for this age group? a. Explain the procedures in detail to alleviate the child’s anxiety. b. Give the child feedback and reassurance during the examination. c. Do not ask the child to remove his or her clothes because children at this age are usually very private. d. Perform an examination of the ear, nose, and throat first, and then examine the thorax and abdomen. B Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS With preschool children, short, simple explanations should be used. Children at this age are usually willing to undress. An examination of the head should be performed last. During the examination, needed feedback and reassurance should be given to the preschooler. 33. When examining a 16-year-old male teenager, the nurse should: a. Discuss health teaching with the parent because the teen is unlikely to be interested in promoting wellness. b. Ask his parent to stay in the room during the history and physical examination to answer any questions and to alleviate his anxiety. c. Talk to him the same manner as one would talk to a younger child because a teen’s level of understanding may not match his or her speech. d. Provide feedback that his body is developing normally, and discuss the wide variation among teenagers on the rate of growth and development. D During the examination, the adolescent needs feedback that his or her body is healthy and developing normally. The adolescent has a keen awareness of Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Standard Precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources and are intended for use for all patients, regardless of their risk or presumed infection status. Standard Precautions apply to blood and all other body fluids, secretions and excretions except sweat—regardless of whether they contain visible blood, nonintact skin, or mucous membranes. Hands should be washed with soap and water if visibly soiled with blood or body fluids. Alcohol-based hand rubs can be used if hands are not visibly soiled. 37. The nurse is preparing to assess a hospitalized patient who is experiencing significant shortness of breath. How should the nurse proceed with the assessment? a. The patient should lie down to obtain an accurate cardiac, respiratory, and abdominal assessment. b. A thorough history and physical assessment information should be obtained from the patient’s family member. c. A complete history and physical assessment should be immediately performed to obtain baseline information. d. Body areas appropriate to the Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS problem should be examined and then the assessment completed after the problem has resolved. D Both altering the position of the patient during the examination and collecting a mini database by examining the body areas appropriate to the problem may be necessary in this situation. An assessment may be completed later after the distress is resolved. 38. When examining an infant, the nurse should examine which area first? a. Ear b. Nose c. Throat d. Abdomen D The least-distressing steps are performed first, saving the invasive steps of the examination of the eye, ear, nose, and throat until last. 39. While auscultating heart sounds, the nurse hears a murmur. Which of these instruments should be used to assess this murmur? a. Electrocardiogram b. Bell of the stethoscope c. Diaphragm of the stethoscope d. Palpation with the nurse’s palm of the hand B The bell of the stethoscope is best for soft, low-pitched sounds such as extra Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS heart sounds or murmurs. The diaphragm of the stethoscope is best used for high-pitched sounds such as breath, bowel, and normal heart sounds. 40. During an examination of a patient’s abdomen, the nurse notes that the abdomen is rounded and firm to the touch. During percussion, the nurse notes a drumlike quality of the sounds across the quadrants. This type of sound indicates: a. Constipation. b. Air-filled areas. c. Presence of a tumor. d. Presence of dense organs. B A musical or drumlike sound (tympany) is heard when percussion occurs over an air- filled viscus, such as the stomach or intestines. 41. The nurse is preparing to examine a 6-year-old child. Which action is most appropriate? a. The thorax, abdomen, and genitalia are examined before the head. b. Talking about the equipment being used is avoided because doing so may increase the child’s anxiety. c. The nurse should keep in mind that a child at this age will have a sense of modesty. Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Chapter 09: 1. The nurse is performing a general survey. Which action is a component of the general survey? a. Observing the patient’s body stature and nutritional status b. Interpreting the subjective information the patient has reported c. Measuring the patient’s temperature, pulse, respirations, and blood pressure d. Observing specific body systems while performing the physical assessment A The general survey is a study of the whole person that includes observing the patient’s physical appearance, body structure, mobility, and behavior. 2. When measuring a patient’s 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. Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS 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 standardized balance scale is used to measure weight. The patient should remove his or her shoes and heavy outer clothing. If a sequence of repeated weights is necessary, then the nurse should attempt to weigh the patient at approximately the same time of day and with the same types of clothing worn each time. 3. A patient’s 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 According to the Seventh Report of the Joint National Committee (JNC 7) guidelines, prehypertension blood pressure readings are systolic readings of 120 to 139 mm Hg or diastolic readings of 50 to 89 mm Hg. Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS 4. During an examination of a child, the nurse considers that physical growth is the best index of a child’s: a. General health. b. Genetic makeup. c. Nutritional status. d. Activity and exercise patterns. A Physical growth is the best index of a child’s general health; recording the child’s height and weight helps determine normal growth patterns. 5. 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 newborn’s head measures approximately 32 to 38 cm and is approximately 2 cm larger than the chest circumference. Between 6 months Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS (TMT) is Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS 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 The TMT is useful for young children who may not cooperate for oral temperatures and fear rectal temperatures. However, the use a TMT with newborn infants and young children is conflicting. 10. 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 B With aging, the nurse keeps in mind that the systolic blood pressure increases, leading to widened pulse pressure. With many older people, both the systolic and diastolic pressures increase. The pulse rate and temperature do not Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS increase. 11. 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 The body maintains a steady temperature through a thermostat or feedback mechanism, which is regulated in the hypothalamus of the brain. The hypothalamus regulates heat production from metabolism, exercise, food digestion, and external factors with heat loss through radiation, evaporation of sweat, convection, and conduction. 12. When measuring a patient’s body temperature, the nurse keeps in mind that body temperature is influenced by: a. Constipation. b. Patient’s emotional state. c. Diurnal cycle. d. Nocturnal cycle. C Normal temperature is influenced by the diurnal cycle, exercise, and age. The other responses do not influence body temperature. 13. When evaluating the temperature of older adults, the nurse should remember which aspect about an older adult’s body temperature? Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS assumptions are not correct. 16. 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 The thermometer should be left in place 3 to 4 minutes if the person is afebrile and up to 8 minutes if the person is febrile. The nurse should wait 15 minutes if the person has just ingested hot or iced liquids and 2 minutes if he or she has just smoked. 17. The nurse is taking temperatures in a clinic with a TMT. Which statement is true regarding use of the TMT? a. A tympanic temperature is more time consuming than a rectal temperature. Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS b. The tympanic method is more invasive and uncomfortable than the oral method. c. The risk of cross-contamination is Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS reduced, compared with the rectal route. d. The tympanic membrane most accurately reflects the temperature in the ophthalmic artery. C The TMT is a noninvasive, nontraumatic device that is extremely quick and efficient. The chance of cross-contamination with the TMT is minimal because the ear canal is lined with skin, not mucous membranes. 18. To assess a rectal temperature accurately in an adult, the nurse would: a. Use a lubricated blunt tip thermometer. b. Insert the thermometer 2 to 3 inches into the rectum. c. Leave the thermometer in place up to 8 minutes if the patient is febrile. d. Wait 2 to 3 minutes if the patient has recently smoked a cigarette. A A lubricated rectal thermometer (with a short, blunt tip) is inserted only 2 to 3 cm (1 inch) into the adult rectum and left in place for 2 minutes. Cigarette smoking does not alter rectal temperatures. 19. Which technique is correct when the nurse is assessing the radial pulse of a patient? The pulse is counted for: Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS felt in the periphery as the pulse. 23. The nurse is assessing the vital signs of a 20-year-old male marathon runner and documents the following vital signs: temperature–36° C; pulse–48 beats per minute; respirations–14 breaths per minute; blood pressure–104/68 mm Hg. Which statement is true concerning these results? a. The patient is experiencing tachycardia. b. These are normal vital signs for a healthy, athletic adult. c. The patient’s pulse rate is not normal—his physician should be notified. d. On the basis of these readings, the patient should return to the clinic in 1 week. B In the adult, a heart rate less than 50 beats per minute is called bradycardia, which normally occurs in the well-trained athlete whose heart muscle develops along with the skeletal muscles. 24. The nurse is assessing the vital signs of a 3-year-old patient who appears to have an irregular respiratory pattern. How should the nurse assess this child’s respirations? a. Respirations should be counted for 1 full minute, noticing rate and rhythm. Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS b. Child’s pulse and respirations should be simultaneously checked for 30 seconds. c. Child’s respirations should be checked for a minimum of 5 minutes to identify any variations in his or her respiratory pattern. d. Patient’s respirations should be counted for 15 seconds and then multiplied by 4 to obtain the number of respirations per minute. A Respirations are counted for 1 full minute if an abnormality is suspected. The other responses are not correct actions. 25. A patient’s blood pressure is 118/82 mm Hg. He asks the nurse, “What do the numbers mean?” The nurse’s best reply is: a. “The numbers are within the normal range and are nothing to worry about.” b. “The bottom number is the diastolic pressure and reflects the stroke volume of the heart.” c. “The top number is the systolic blood pressure and reflects the pressure of the blood against the arteries when the heart contracts.” Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS d. “The concept of blood pressure is difficult to understand. The primary thing to be Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS assessment. B Using a cuff that is too narrow yields a falsely high blood pressure because it takes extra pressure to compress the artery. 29. A student is late for his appointment and has rushed across campus to the health clinic. The nurse should: a. Allow 5 minutes for him to relax and rest before checking his vital signs. b. Check the blood pressure in both arms, expecting a difference in the readings because of his recent exercise. c. Immediately monitor his vital signs on his arrival at the clinic and then 5 minutes later, recording any differences. d. Check his blood pressure in the supine position, which will provide a more accurate reading and will allow him to relax at the same time. A A comfortable, relaxed person yields a valid blood pressure. Many people are anxious at the beginning of an examination; the nurse should allow at least a 5-minute rest period before measuring blood pressure. Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS 30. The nurse will perform a palpated pressure before auscultating blood pressure. The reason for this is to: a. More clearly hear the Korotkoff sounds. b. Detect the presence of an auscultatory gap. c. Avoid missing a falsely elevated blood pressure. d. More readily identify phase IV of the Korotkoff sounds. B Inflation of the cuff 20 to 30 mm Hg beyond the point at which a palpated pulse disappears will avoid missing an auscultatory gap, which is a period when the Korotkoff sounds disappear during auscultation. 31. The nurse is taking an initial blood pressure reading on a 72-year-old patient with documented hypertension. How should the nurse proceed? a. Cuff should be placed on the patient’s arm and inflated 30 mm Hg above the patient’s pulse rate. b. Cuff should be inflated to 200 mm Hg in an attempt to obtain the most accurate systolic reading. c. Cuff should be inflated 30 mm Hg above the point at which the palpated pulse disappears. Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS d. After confirming the patient’s previous blood pressure readings, the cuff should be inflated 30 mm Hg above the highest systolic reading recorded. C An auscultatory gap occurs in approximately 5% of the people, most often in those with hypertension. To check for the presence of an auscultatory gap, the cuff should be inflated 20 to 30 mm Hg beyond the point at which the palpated pulse disappears. 32. The nurse has collected the following information on a patient: palpated blood pressure– 180 mm Hg; auscultated blood pressure–170/100 mm Hg; apical pulse–60 beats per minute; radial pulse–70 beats per minute. What is the patient’s pulse pressure? a. 10 b. 70 c. 80 d. 100 B Pulse pressure is the difference between systolic and diastolic blood pressure (170 – 100 = 70) and reflects the stroke volume. 33. When auscultating the blood pressure of a 25-year-old patient, the nurse notices the phase I Korotkoff sounds begin at 200 mm Hg. At 100 mm Hg, the Korotkoff sounds muffle. At 92 mm Hg, the Korotkoff sounds disappear. How should the nurse record this patient’s blood pressure? Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS b. The best position to measure thigh pressure is the supine position with the knee slightly bent. c. If the blood pressure in the arm is high in an adolescent, then it should be compared with the thigh pressure. d. The thigh pressure is lower than the pressure in the arm, which is attributable to the distance away from the heart and the size of the popliteal vessels. C When blood pressure measured at the arm is excessively high, particularly in adolescents and young adults, it is compared with thigh pressure to check for coarctation of the aorta. The popliteal artery is auscultated for the reading. Generally, thigh pressure is higher than that of the arm; however, if coarctation of the artery is present, then arm pressures are higher than thigh pressures. 37. The nurse is preparing to measure the vital signs of a 6-month-old infant. Which action by the nurse is correct? a. Respirations are measured; then pulse and temperature. b. Vital signs should be measured more frequently than in an adult. Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS c. Procedures are explained to the parent, and the infant is encouraged to handle the equipment. d. The nurse should first perform the physical examination to allow the infant to become more familiar with her and then measure the infant’s vital signs. A With an infant, the order of vital sign measurements is reversed to respiration, pulse, and temperature. Taking the temperature first, especially if it is rectal, may cause the infant to cry, which will increase the respiratory and pulse rate, thus masking the normal resting values. The vital signs are measured with the same purpose and frequency as would be measured in an adult. 38. A 4-month-old child is at the clinic for a well-baby check-up and immunizations. Which of these actions is most appropriate when the nurse is assessing an infant’s vital signs? a. The infant’s radial pulse should be palpated, and the nurse should notice any fluctuations resulting from activity or exercise. b. The nurse should auscultate an apical rate for 1 minute and then assess for any normal irregularities, such as sinus arrhythmia. c. The infant’s blood pressure Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS should be assessed by using a stethoscope with a large diaphragm piece to hear the soft muffled Korotkoff sounds. d. The infant’s chest should be observed and the respiratory rate counted for 1 minute; the respiratory pattern may vary significantly. B The nurse palpates or auscultates an apical rate with infants and toddlers. The pulse should be counted for 1 full minute to account for normal irregularities, such as sinus arrhythmia. Children younger than 3 years of age have such small arm vessels; consequently, hearing Korotkoff sounds with a stethoscope is difficult. The nurse should use either an electronic blood pressure device that uses oscillometry or a Doppler ultrasound device to amplify the sounds. 39. The nurse is conducting a health fair for older adults. Which statement is true regarding vital sign measurements in aging adults? a. The pulse is more difficult to palpate because of the stiffness of the blood vessels. b. An increased respiratory rate and a shallower inspiratory phase are expected findings. c. A decreased pulse pressure occurs from changes in the systolic and Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS a. When standing, the patient’s base is narrow. b. The patient appears older than his stated age. c. Arm span (fingertip to fingertip) is greater than the height. d. Arm span (fingertip to fingertip) equals the patient’s height. D When performing the general survey, the patient’s arm span (fingertip to fingertip) should equal the patient’s height. An arm span that is greater than the person’s height may indicate Marfan syndrome. The base should be wide when the patient is standing, and an older appearance than the stated age may indicate a history of a chronic illness or chronic alcoholism. 42. The nurse is assessing children in a pediatric clinic. Which statement is true regarding the measurement of blood pressure in children? a. Blood pressure guidelines for children are based on age. b. Phase II Korotkoff sounds are the best indicator of systolic blood pressure in children. c. Using a Doppler device is recommended for accurate blood pressure measurements until adolescence. d. The disappearance of phase V Korotkoff sounds can be used for Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS the diastolic reading in children. D The disappearance of phase V Korotkoff sounds can be used for the diastolic reading in children, as well as in adults. 43. What type of blood pressure measurement error is most likely to occur if the nurse does not check for the presence of an auscultatory gap? a. Diastolic blood pressure may not be heard. b. Diastolic blood pressure may be falsely low. c. Systolic blood pressure may be falsely low. d. Systolic blood pressure may be falsely high. C If an auscultatory gap is undetected, then a falsely low systolic or falsely high diastolic reading may result, which is common in patients with hypertension. 44. When considering the concepts related to blood pressure, the nurse knows that the concept of mean arterial pressure (MAP) is best described by which statement? a. MAP is the pressure of the arterial pulse. b. MAP reflects the stroke volume of the heart. c. MAP is the pressure forcing blood Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS into the tissues, averaged over the cardiac cycle. d. MAP is an average of the systolic and diastolic blood pressures and reflects tissue perfusion. C MAP is the pressure that forces blood into the tissues, averaged over the cardiac cycle. Stroke volume is reflected by the blood pressure. MAP is not an arithmetic average of systolic and diastolic pressures because diastole lasts longer; rather, it is a value closer to diastolic pressure plus one third of the pulse pressure. 45. A 75-year-old man with a history of hypertension was recently changed to a new antihypertensive drug. He reports feeling dizzy at times. How should the nurse evaluate his blood pressure? a. Blood pressure and pulse should be recorded in the supine, sitting, and standing positions. b. The patient should be directed to walk around the room and his blood pressure assessed after this activity. c. Blood pressure and pulse are assessed at the beginning and at the end of the examination. d. Blood pressure is taken on the Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS appropriate for all sizes. b. The length of the rubber bladder should equal 80% of the arm circumference. c. The width of the rubber bladder should equal 80% of the arm circumference. d. The width of the rubber bladder should equal 40% of the arm circumference. D The width of the rubber bladder should equal 40% of the circumference of the person's arm. The length of the bladder should equal 80% of this circumference. 50. During an examination, the nurse notices that a female patient has a round “moon” face, central trunk obesity, and a cervical hump. Her skin is fragile with bruises. The nurse determines that the patient has which condition? a. Marfan syndrome b. Gigantism c. Cushing syndrome d. Acromegaly C Cushing syndrome is characterized by weight gain and edema with central trunk and cervical obesity (buffalo hump) and round plethoric face (moon face). Excessive catabolism causes muscle wasting; weakness; thin arms and legs; reduced height; and thin, fragile skin with purple abdominal striae, Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS bruising, and acne. (See Table 9-5, Abnormalities in Body Height and Proportion, for the definitions of the other conditions.) MULTIPLE RESPONSE 1. While measuring a patient’s blood pressure, the nurse uses the proper technique to obtain an accurate reading. Which of these situations will result in a falsely high blood pressure reading? Select all that apply. a. The person supports his or her own arm during the blood pressure reading. b. The blood pressure cuff is too narrow for the extremity. c. The arm is held above level of the heart. d. The cuff is loosely wrapped around the arm. e. The person is sitting with his or her legs crossed. f. The nurse does not inflate the cuff high enough. A, B, D, E Several factors can result in blood pressure readings that are too high or too low. Having the patient’s arm held above the level of the heart is one part of the correct technique. (Refer to Table 9-5, Common Errors in Blood Pressure Measurement.) SHORT ANSWER Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS 1. What is the pulse pressure for a patient whose blood pressure is 158/96 mm Hg and whose pulse rate is 72 beats per minute? 62 The pulse pressure is the difference between the systolic and diastolic and reflects the stroke volume. The pulse rate is not necessary for pulse pressure calculations. Chapter 10: 1. When evaluating a patient’s pain, the nurse knows that an example of acute pain would be: a. Arthritic pain. b. Fibromyalgia. c. Kidney stones. d. Low back pain. C Acute pain is short-term and dissipates after an injury heals, such as with kidney stones. The other conditions are examples of chronic pain during which the pain continues for 6 months or longer and does not stop when the injury heals. 2. Which statement indicates that the nurse understands the pain experienced by an older adult? a. “Older adults must learn to tolerate Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS associated with nausea, pallor, and diaphoresis. d. Slightest touch, such as a sleeve brushing against her arm, causes severe and intense pain. D A key feature of reflexive sympathetic dystrophy is that a typically innocuous stimulus can create a severe, intensely painful response. The affected extremity becomes less functional over time. 6. The nurse is assessing a patient’s pain. The nurse knows that the most reliable indicator of pain would be the: a. Patient’s vital signs. b. Physical examination. c. Results of a computerized axial tomographic scan. d. Subjective report. D The subjective report is the most reliable indicator of pain. Physical examination findings can lend support, but the clinician cannot exclusively base the diagnosis of pain on physical assessment findings. 7. A patient has had arthritic pain in her hips for several years since a hip fracture. She is able to move around in her room and has not offered any complaints so far this morning. However, when asked, she states that her Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS pain is “bad this morning” and rates it at an 8 on a 1-to-10 scale. What does the nurse suspect? The patient: a. Is addicted to her pain medications and cannot obtain pain relief. b. Does not want to trouble the nursing staff with her complaints. c. Is not in pain but rates it high to receive pain medication. d. Has experienced chronic pain for years and has adapted to it. D Persons with chronic pain typically try to give little indication that they are in pain and, over time, adapt to the pain. As a result, they are at risk for underdetection. 8. The nurse is reviewing the principles of pain. Which type of pain is due to an abnormal processing of the pain impulse through the peripheral or central nervous system? a. Visceral b. Referred c. Cutaneous d. Neuropathic D Neuropathic pain implies an abnormal processing of the pain message. The other types of pain are named according to their sources. Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS 9. When assessing the quality of a patient’s pain, the nurse should ask which question? a. “When did the pain start?” b. “Is the pain a stabbing pain?” c. “Is it a sharp pain or dull pain?” d. “What does your pain feel like?” D To assess the quality of a person’s pain, the patient is asked to describe the pain in his or her own words. 10. When assessing a patient’s pain, the nurse knows that an example of visceral pain would be: a. Hip fracture. b. Cholecystitis. c. Second-degree burns. d. Pain after a leg amputation. B Visceral pain originates from the larger interior organs, such as the gallbladder, liver, or kidneys. 11. The nurse is reviewing the principles of nociception. During which phase of nociception does the conscious awareness of a painful sensation occur? a. Perception b. Modulation c. Transduction d. Transmission Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS by physiologic changes, such as an increased heart rate. b. The FPS-R can be used to assess pain in infants. c. A procedure that induces pain in adults will also induce pain in the infant. d. Infants feel pain less than do adults. C If a procedure or disease process causes pain in an adult, then it will also cause pain in an infant. Physiologic changes cannot be exclusively used to confirm or deny pain because other factors, such as medications, fluid status, or stress may cause physiologic changes. The FPS-R can be used starting at age 4 years. 15. A patient has been admitted to the hospital with vertebral fractures related to osteoporosis. She is in extreme pain. This type of pain would be classified as: a. Referred. b. Cutaneous. c. Visceral. d. Deep somatic. D Deep somatic pain comes from sources such as the blood vessels, joints, tendons, muscles, and bone. Referred pain is felt at one site but originates from another location. Cutaneous pain is derived from the skin surface and subcutaneous tissues. Visceral pain originates from the larger, interior Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS organs. MULTIPLE RESPONSE 1. During assessment of a patient’s pain, the nurse is aware that certain nonverbal behaviors are associated with chronic pain. Which of these behaviors are associated with chronic pain? Select all that apply. a. Sleeping b. Moaning c. Diaphoresis d. Bracing e. Restlessness f. Rubbing A, D, F Behaviors that have been associated with chronic pain include bracing, rubbing, diminished activity, sighing, and changes in appetite. In addition, those with chronic pain may sleep in an attempt at distraction. The other behaviors are associated with acute pain. 2. During an admission assessment of a patient with dementia, the nurse assesses for pain because the patient has recently had several falls. Which of these are appropriate for the nurse to assess in a patient with dementia? Select all that apply. a. Ask the patient, “Do you have pain?” b. Assess the patient’s breathing independent of vocalization. Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS c. Note whether the patient is calling out, groaning, or crying. d. Have the patient rate pain on a 1-to-10 scale. e. Observe the patient’s body language for pacing and agitation. B, C, E Patients with dementia may say “no” when, in reality, they are very uncomfortable because words have lost their meaning. Patients with dementia become less able to identify and describe pain over time, although pain is still present. People with dementia communicate pain through their behaviors. Agitation, pacing, and repetitive yelling may indicate pain and not a worsening of the dementia. (See Figure 10-10 for the Pain Assessment in Advanced Dementia [PAINAD] scale, which may also be used to assess pain in persons with dementia.) Chapter 11: 1. The nurse recognizes which of these persons is at greatest risk for undernutrition? a. 5-month-old infant b. 50-year-old woman c. 20-year-old college student d. 30-year-old hospital administrator A Vulnerable groups for undernutrition are infants, children, pregnant women, Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS decreased. d. The baby should be placed on skim milk to decrease the risk of coronary artery disease when he or she grows older. A Because of rapid growth, especially of the brain, both infants and children younger than 2 years of age should not drink skim or low-fat milk or be placed on low-fat diets. Fats (calories and essential fatty acids) are required for proper growth and central nervous system development. 4. A pregnant woman is interested in breastfeeding her baby and asks several questions about the topic. Which information is appropriate for the nurse to share with her? a. Breastfeeding is best when also supplemented with bottle feedings. b. Babies who are breastfed often require supplemental vitamins. c. Breastfeeding is recommended for infants for the first 2 years of life. d. Breast milk provides the nutrients necessary for growth, as well as natural immunity. D Breastfeeding is recommended for full-term infants for the first year of life because breast milk is ideally formulated to promote normal infant growth and development, as well as natural immunity. The other statements are not Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS correct. 5. A mother and her 13-year-old daughter express their concern related to the daughter’s recent weight gain and her increase in appetite. Which of these statements represents information the nurse should discuss with them? a. Dieting and exercising are necessary at this age. b. Snacks should be high in protein, iron, and calcium. c. Teenagers who have a weight problem should not be allowed to snack. d. A low-calorie diet is important to prevent the accumulation of fat. B After a period of slow growth in late childhood, adolescence is characterized by rapid physical growth and endocrine and hormonal changes. Caloric and protein requirements increase to meet this demand. Because of bone growth and increasing muscle mass (and, in girls, the onset of menarche), calcium and iron requirements also increase. 6. The nurse is assessing a 30-year-old unemployed immigrant from an underdeveloped country who has been in the United States for 1 month. Which of these problems related to his nutritional status might the nurse expect to find? a. Obesity b. Hypotension Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS c. Osteomalacia (softening of the bones) d. Coronary artery disease C General undernutrition, hypertension, diarrhea, lactose intolerance, osteomalacia, scurvy, and dental caries are among the more common nutrition-related problems of new immigrants from developing countries. 7. For the first time, the nurse is seeing a patient who has no history of nutrition-related problems. The initial nutritional screening should include which activity? a. Calorie count of nutrients b. Anthropometric measures c. Complete physical examination d. Measurement of weight and weight history D Parameters used for nutrition screening typically include weight and weight history, conditions associated with increased nutritional risk, diet information, and routine laboratory data. The other responses reflect a more in-depth assessment rather than a screening. 8. A patient is asked to indicate on a form how many times he eats a specific food. This method describes which of these tools for obtaining dietary information? a. Food diary b. Calorie count Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS 12. The nurse is performing a nutritional assessment on a 15-year-old girl who tells the nurse that she is “so fat.” Assessment reveals that she is 5 feet 4 inches and weighs 110 pounds. The nurse’s appropriate response would be: a. “How much do you think you should weigh?” b. “Don’t worry about it; you’re not that overweight.” c. “The best thing for you would be to go on a diet.” d. “I used to always think I was fat when I was your age.” A Adolescents’ increased body awareness and self-consciousness may cause eating disorders such as anorexia nervosa or bulimia, conditions in which the real or perceived body image does not favorably compare with an ideal image. The nurse should not belittle the adolescent’s feelings, provide unsolicited advice, or agree with her. 13. The nurse is discussing appropriate foods with the mother of a 3-year-old child. Which of these foods are recommended? a. Foods that the child will eat, no matter what they are b. Foods easy to hold such as hot dogs, nuts, and grapes c. Any foods, as long as the rest of the family is also eating them Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS d. Finger foods and nutritious snacks that cannot cause choking D Small portions, finger foods, simple meals, and nutritious snacks help improve the dietary intake of young children. Foods likely to be aspirated should be avoided (e.g., hot dogs, nuts, grapes, round candies, popcorn). 14. The nurse is reviewing the nutritional assessment of an 82-year-old patient. Which of these factors will most likely affect the nutritional status of an older adult? a. Increase in taste and smell b. Living alone on a fixed income c. Change in cardiovascular status d. Increase in gastrointestinal motility and absorption B Socioeconomic conditions frequently affect the nutritional status of the aging adult; these factors should be closely evaluated. Physical limitations, income, and social isolation are frequent problems that interfere with the acquisition of a balanced diet. A decrease in taste and smell and decreased gastrointestinal motility and absorption occur with aging. Cardiovascular status is not a factor that affects an older adult’s nutritional status. 15. When considering a nutritional assessment, the nurse is aware that the most common anthropometric measurements include: a. Height and weight. b. Leg circumference. Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS c. Skinfold thickness of the biceps. d. Hip and waist measurements. A The most commonly used anthropometric measures are height, weight, triceps skinfold thickness, elbow breadth, and arm and head circumferences. 16. If a 29-year-old woman weighs 156 pounds, and the nurse determines her ideal body weight to be 120 pounds, then how would the nurse classify the woman’s weight? a. Obese b. Mildly overweight c. Suffering from malnutrition d. Within appropriate range of ideal weight A Obesity, as a result of caloric excess, refers to weight more than 20% above ideal body weight. For this patient, 20% of her ideal body weight would be 24 pounds, and greater than 20% of her body weight would be over 144 pounds. Therefore, having a weight of 156 pounds would be considered obese. 17. How should the nurse perform a triceps skinfold assessment? a. After pinching the skin and fat, the calipers are vertically applied to the fat fold. b. The skin and fat on the front of the Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS important for the nurse to include in patient teaching in relation to these tests? Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS a. The risks of undernutrition should be included. b. Offer methods to reduce the stress in her life. c. Provide information regarding a diet low in saturated fat. d. This condition is hereditary; she can do nothing to change the levels. C The patient with elevated cholesterol and triglyceride levels should be taught about eating a healthy diet that limits the intake of foods high in saturated fats or trans fats. Reducing dietary fats is part of the treatment for this condition. The other responses are not pertinent to her condition. 21. In performing an assessment on a 49-year-old woman who has imbalanced nutrition as a result of dysphagia, which data would the nurse expect to find? a. Increase in hair growth b. Inadequate nutrient food intake c. Weight 10% to 20% over ideal d. Sore, inflamed buccal cavity B Dysphagia, or impaired swallowing, interferes with adequate nutrient intake. 22. A 21-year-old woman has been on a low-protein liquid diet for the past 2 Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS months. She has had adequate intake of calories and appears well nourished. After further assessment, what would the nurse expect to find? a. Poor skin turgor b. Decreased serum albumin c. Increased lymphocyte count d. Triceps skinfold less than standard B Kwashiorkor (protein malnutrition) is due to diets that may be high in calories but contain little or no protein (e.g., low-protein liquid diets, fad diets, and long-term use of dextrose- containing intravenous fluids). The serum albumin would be less than 3.5 g/dL. 23. The nurse is performing a nutritional assessment on an 80-year-old patient. The nurse knows that physiologic changes can directly affect the nutritional status of the older adult and include: a. Slowed gastrointestinal motility. b. Hyperstimulation of the salivary glands. c. Increased sensitivity to spicy and aromatic foods. d. Decreased gastrointestinal absorption causing esophageal reflux. A Normal physiologic changes in aging adults that affect nutritional status include slowed gastrointestinal motility, decreased gastrointestinal absorption, diminished olfactory and taste sensitivity, decreased saliva production, decreased visual acuity, and poor dentition. Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS D DEXA measures both bone mineral density and fat and lean body mass. BIA measures fat and lean body mass but not bone mineral density. A measuring tape measures distance or length, and skinfold calipers are used to determine skinfold thickness. 27. Which of these conditions is due to an inadequate intake of both protein and calories? a. Obesity b. Bulimia c. Marasmus d. Kwashiorkor C Marasmus, protein-calorie malnutrition, is due to an inadequate intake of protein and calories or prolonged starvation. Obesity is due to caloric excess; bulimia is an eating disorder. Kwashiorkor is protein malnutrition. 28. During an assessment of a patient who has been homeless for several years, the nurse notices that his tongue is magenta in color, which is an indication of a deficiency in what mineral and/or vitamin? a. Iron b. Riboflavin c. Vitamin D and calcium d. Vitamin C B Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Magenta tongue is a sign of riboflavin deficiency. In contrast, a pale tongue is probably attributable to iron deficiency. Vitamin D and calcium deficiencies cause osteomalacia in adults, and a vitamin C deficiency causes scorbutic gums. 29. A 50-year-old patient has been brought to the emergency department after a housemate found that the patient could not get out of bed alone. He has lived in a group home for years but for several months has not participated in the activities and has stayed in his room. The nurse assesses for signs of undernutrition, and an x-ray study reveals that he has osteomalacia, which is a deficiency of: a. Iron. b. Riboflavin. c. Vitamin D and calcium. d. Vitamin C. C Osteomalacia results from a deficiency of vitamin D and calcium in adults. Iron deficiency would result in anemia, riboflavin deficiency would result in magenta tongue, and vitamin C deficiency would result in scurvy. 30. An older adult patient in a nursing home has been receiving tube feedings for several months. During an oral examination, the nurse notes that patient’s gums are swollen, ulcerated, and bleeding in some areas. The nurse suspects that the patient has what condition? a. Rickets b. Vitamin A deficiency c. Linoleic-acid deficiency Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS d. Vitamin C deficiency D Vitamin C deficiency causes swollen, ulcerated, and bleeding gums, known as scorbutic gums. Rickets is a condition related to vitamin D and calcium deficiencies in infants and children. Linoleic-acid deficiency causes eczematous skin. Vitamin A deficiency causes Bitot spots and visual problems. 31. The nurse is assessing the body weight as a percentage of ideal body weight on an adolescent patient who was admitted for suspected anorexia nervosa. The patient’s usual weight was 125 pounds, but today she weighs 98 pounds. The nurse calculates the patient’s ideal body weight and concludes that the patient is: a. Experiencing mild malnutrition. b. Experiencing moderate malnutrition. c. Experiencing severe malnutrition. d. Still within expected parameters with her current weight. B By dividing her current weight by her usual weight and then multiplying by 100, a percentage of 78.4% is obtained, which means that her current weight is 78.4% of her ideal body weight. A current weight of 80% to 90% of ideal weight suggests mild malnutrition; a current weight of 70% to 80% of ideal weight suggests moderate malnutrition; a current weight of less than 70% of ideal weight suggests severe malnutrition. MULTIPLE RESPONSE Health Assessment Exam 2: Study Guide Best Exam Solution With Compresive Revision for Graded A+ STUDENTS