Physical Examination and Health Assessment CANADIAN 3rd Edition Jarvis Test Bank
Chapter 10: General Survey, Measurement, Vital Signs
Jarvis: Physical Examination & Health Assessment, 3rd Canadian edition
MULTIPLE CHOICE
1. The nurse is performing a general survey. The nurse:
a. Observes the patient’s body stature and nutritional status.
b. Interprets the subjective information the patient has reported.
c. Measures the patient’s temperature, pulse, respirations, and blood pressure.
d. Observes specific body systems while performing the physical assessment.
ANS: A
The general survey is a study of the whole person that includes observing the patient’s
physical appearance, body structure, mobility, and behaviour.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
2. When measuring a patient’s weight, the nurse will:
a. Weigh the patient wearing only undergarments.
b. Aim for similar daily weights regardless of type of scale used.
c. Allow the patient to keep the jacket and shoes on as long as these are documented
next to the weight.
d. Weigh the patient at the same time daily for a sequence of weights.
ANS: D [Link]
A standardized balance or electronic standing 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.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
3. A patient takes weekly home blood pressure readings, with average reading being 126/82
mm Hg. The nurse recognizes that the patient:
a. Has hypertension.
b. Is normotensive.
c. Needs to increase exercise for weight loss.
d. Needs to decrease alcohol intake.
ANS: B
According to the Canadian Health Education Program (CHEP) recommendations a blood
pressure under 135/85 mm Hg warrants continued follow-up, not a diagnosis of
hypertension.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
[Link]
Physical Examination and Health Assessment CANADIAN 3rd Edition Jarvis Test Bank
4. While examining a 7-year-old patient, the nurse uses physical growth as the best index of
the child’s:
a. General health.
b. Genetic makeup.
c. Nutritional status.
d. Activity and exercise patterns.
ANS: 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.
DIF: Cognitive Level: Remembering (Knowledge)
MSC: Client Needs: Health Promotion and Maintenance
5. The nurse assesses a 1-month-old infant to have a head measurement of 34 cm and a chest
circumference of 32 cm. The nurse will:
a. Refer the infant to a physician for further evaluation.
b. Document the findings as normal for a 1-month-old infant.
c. Request that another nurse recheck the findings.
d. Ask the parent to return in 2 weeks to re-evaluate the head and chest
circumferences.
ANS: B
The newborn’s head measures approximately 32 to 38 cm and is approximately 2 cm larger
than the chest circumference. Between 6 months and 2 years, both measurements are
approximately the same, and after age 2 years, the chest circumference is greater than the
head circumference.
[Link]
DIF: Cognitive Level: Analyzing (Analysis)
MSC: Client Needs: Health Promotion and Maintenance
6. 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
ANS: C
Changes that occur in the aging person include more prominent bony landmarks, decreased
body weight (especially in men), a decrease in subcutaneous fat from the face and periphery,
and additional fat deposited on the abdomen and hips. Postural changes of kyphosis and
slight flexion in the knees and hips also occur.
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Health Promotion and Maintenance
7. The nurse should measure rectal temperatures in which of these patients?
a. School-age child
[Link]
Physical Examination and Health Assessment CANADIAN 3rd Edition Jarvis Test Bank
b. Older adult
c. Comatose adult
d. Patient receiving oxygen by nasal cannula
ANS: C
Rectal temperatures should be taken when the other routes are impractical, such as in
comatose or confused persons, those in shock, or those who cannot close the mouth because
of breathing or oxygen tubes, a wired mandible, or other facial dysfunctions.
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
8. 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 infant’s 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
ANS: C
To measure the chest circumference, the tape is encircled around the chest at the nipple line.
The length should be measured on a horizontal measuring board. Weight should be
measured on a platform-type balance scale. Head circumference is measured with the tape
around the head, aligned at the eyebrows, and at the prominent frontal and occipital
bones—the widest span is correct.
N R I G B.C M
U S (Application)
DIF: Cognitive Level: Applying N T O
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
9. The nurse decides to use the temporal artery thermometer (TAT) with the 4-year-old patient
because it is:
a. A useful rapid measurement for younger children.
b. The most accurate method for measuring body temperature in newborn infants.
c. The least expensive method of measuring temperature.
d. Well-supported by evidence for measuring temperature with children under age 6
years.
ANS: A
The TAT is useful for young children who may not be able to cooperate for oral
temperatures and fear disrobing and the invasiveness of rectal temperatures. However,
evidence on the use a TAT in newborn infants and young children is conflicting.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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
[Link]
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d. Decrease in diastolic blood pressure
ANS: 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 increase.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Health Promotion and Maintenance
11. The nurse is examining a patient who is sweaty and complaining of “feeling cold.” The
nurse recognizes that the patient is losing heat through:
a. Exercise.
b. Evaporation.
c. Metabolism.
d. Food digestion.
ANS: 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.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: General
12. The nurse measures the patient’s
NURStemperature
[Link] 37.3C during the afternoon. After
comparing with the morning temperature of 36C, the nurse:
a. Informs the physician that the patient has a temperature.
b. Recognizes that the patient’s emotions are influencing her temperature.
c. Documents the temperature as a normal finding.
d. Is concerned that the patient is too cold.
ANS: C
Normal temperature is influenced by the diurnal cycle, exercise, and age. A diurnal cycle
can influence temperature by 1C to 1.5C, with the trough occurring in the early morning
hours and the peak in late afternoon to early evening.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: General
13. When evaluating the temperature of older adults, the nurse knows that:
a. The body temperature of the older adult is lower than that of a younger adult.
b. An older adult’s 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.
ANS: A
[Link]
Physical Examination and Health Assessment CANADIAN 3rd Edition Jarvis Test Bank
In older adults, the body temperature is usually lower than in other age groups, with a mean
temperature of 36.2° C.
DIF: Cognitive Level: Remembering (Knowledge)
MSC: Client Needs: Health Promotion and Maintenance
14. 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 past 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.
ANS: C
An unexplained weight loss may be a sign of a short-term illness or a chronic illness, such
as endocrine disease, malignancy, depression, anorexia nervosa, or bulimia.
DIF: Cognitive Level: Analyzing (Analysis)
MSC: Client Needs: Physiologic Integrity: Basic Care and Comfort
15. 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. The nurse:
a. Assumes that the patient is eager and interested in participating in the interview.
b. Evaluates the patient for abdominal pain, which may be exacerbated in the sitting
position.
c. Assumes that the patient NU
isR SINGdifficulty
having [Link]
M and assists him to the supine
position.
d. Recognizes that a tripod position is often used when a patient is having respiratory
difficulties.
ANS: D
Assuming a tripod position—leaning forward with arms braced on chair arms—occurs with
chronic obstructive pulmonary disease (COPD). The other actions or assumptions are not
correct.
DIF: Cognitive Level: Analyzing (Analysis)
MSC: Client Needs: Physiologic Integrity: Basic Care and Comfort
16. Which of these actions illustrates the correct technique the nurse should use when assessing
oral temperature with a mercury thermometer?
a. Waiting 30 minutes if the patient has ingested hot or iced liquids
b. Leaving the thermometer in place 3 to 4 minutes if the patient is afebrile
c. Placing the thermometer in front of the tongue and asking the patient to close the
lips.
d. Shaking the mercury-in-glass thermometer down to below 36.6°C before taking
the temperature.
ANS: B
[Link]
Physical Examination and Health Assessment CANADIAN 3rd Edition Jarvis Test Bank
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.
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
17. The nurse is taking temperatures in a clinic with a tympanic membrane thermometer (TMT).
Which statement is true regarding use of the TMT?
a. Taking tympanic temperature is more time consuming than taking rectal
temperature.
b. The tympanic method is more invasive and uncomfortable than the oral method.
c. The risk for cross-contamination is reduced, compared with the rectal route.
d. The tympanic membrane most accurately reflects the temperature in the
ophthalmic artery.
ANS: C
The TMT is a noninvasive, nontraumatic device that is extremely quick and efficient to use.
The chance of cross-contamination with the TMT is minimal because the ear canal is lined
with skin, not mucous membranes.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
18. To assess a rectal temperature accurately in an adult, the nurse would:
a. Use a lubricated cover over a blunt tip electronic thermometer.
b. Insert the thermometer N2UtoR3Sinches
INGTintoB.C M
theOrectum.
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.
ANS: A
A lubricated rectal probe cover over an electronic 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.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
19. When assessing the radial pulse of a patient, the nurse will count the pulse for:
a. 1 minute, if the rhythm is irregular.
b. 15 seconds and then multiply by 4, if the rhythm is regular.
c. 2 full minutes to detect any variation in amplitude.
d. 10 seconds and then multiply by 6, if the patient has no history of cardiac
abnormalities.
ANS: A
Recent research suggests that the 30-second interval multiplied by 2 is the most accurate and
efficient technique when heart rates are normal or rapid and when rhythms are regular. If the
rhythm is irregular, then the pulse is counted for 1 full minute.
[Link]
Physical Examination and Health Assessment CANADIAN 3rd Edition Jarvis Test Bank
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
20. When assessing a patient’s pulse, the nurse will also assess:
a. Force.
b. Pallor.
c. Capillary refill time.
d. Timing in the cardiac cycle.
ANS: A
The pulse is assessed for rate, rhythm, and force.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
21. When assessing the pulse of a 6-year-old boy, the nurse notices that his heart rate varies
with his respiratory cycle, speeding up at the peak of inspiration and slowing to normal with
expiration. The nurse’s next action would be to:
a. Immediately notify the physician.
b. Consider this finding normal in children and young adults.
c. Check the child’s blood pressure and note any variation with respiration.
d. Document that this child has bradycardia and continue with the assessment.
ANS: B
Sinus arrhythmia is commonly found in children and young adults. During the respiratory
cycle, the heart rate varies, speeding up at the peak of inspiration and slowing to normal
with expiration.
[Link]
DIF: Cognitive Level: Analyzing (Analysis)
MSC: Client Needs: Health Promotion and Maintenance
22. When assessing the force, or strength, of a pulse, the nurse recalls that the pulse:
a. Is usually recorded on a 0-2–point scale.
b. Demonstrates elasticity of the vessel wall.
c. Is a reflection of the heart’s stroke volume.
d. Reflects the blood volume in the arteries during diastole.
ANS: C
The heart pumps an amount of blood (the stroke volume) into the aorta. The force flares the
arterial walls and generates a pressure wave, which is felt in the periphery as the pulse.
DIF: Cognitive Level: Remembering (Knowledge)
MSC: Client Needs: General
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.
[Link]
Physical Examination and Health Assessment CANADIAN 3rd Edition Jarvis Test Bank
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.
ANS: 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.
DIF: Cognitive Level: Analyzing (Analysis)
MSC: Client Needs: Health Promotion and Maintenance
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.
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.
ANS: A
Respirations are counted for 1 full minute if an abnormality is suspected. The other
responses are not correct actions.
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Health Promotion and Maintenance
N R I G B.C M
25. A patient’s blood pressure isU S NmmTHg. HeOasks the nurse, “What do the numbers
118/82
mean?” The nurse’s best reply is:
a. “The numbers are within the normal range, and there is 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.”
d. “The concept of blood pressure is difficult to understand. The primary thing to be
concerned about is the top number, or the systolic blood pressure.”
ANS: C
The systolic pressure is the maximum pressure felt on the artery during left ventricular
contraction, or systole. The diastolic pressure is the elastic recoil, or resting, pressure that
the blood constantly exerts in between each contraction. The nurse should answer the
patient’s question and use terms he can understand.
DIF: Cognitive Level: Analyzing (Analysis)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
26. While measuring a patient’s blood pressure, the nurse recalls that certain factors, such as
_________________, help determine blood pressure.
a. Pulse rate
b. Pulse pressure
[Link]
Physical Examination and Health Assessment CANADIAN 3rd Edition Jarvis Test Bank
c. Vascular output
d. Peripheral vascular resistance
ANS: D
The level of blood pressure is determined by five factors: cardiac output, peripheral vascular
resistance, volume of circulating blood, viscosity, and elasticity of the vessel walls.
DIF: Cognitive Level: Remembering (Knowledge)
MSC: Client Needs: General
27. A nurse is helping at a health fair at the local mall. When taking blood pressures on a variety
of people, the nurse keeps in mind that:
a. After menopause, blood pressure readings in women are usually lower than those
in men.
b. The blood pressure of an adult of African descent is usually higher than that of an
adult of European descent and of the same age.
c. Blood pressure measurements in people who are overweight should be the same as
those of people who are at a normal weight.
d. A teenager’s blood pressure reading will be lower than that of an adult.
ANS: B
In Canada, adults of African descent usually have a higher blood pressure compared with
those of European descent and of the same age. The incidence of hypertension is twice as
high among those of African descent; reasons for the difference are not fully understood, but
it appears to be a result of genetic and environmental factors. After menopause, blood
pressure in women is higher than in men; blood pressure measurements in people who are
obese are usually higher than in those who are not overweight. Normally, a gradual rise
N RSIthe
occurs through childhood andUinto NGadult
TB.C OM
years.
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Physiologic Integrity
28. The nurse notices that a colleague is preparing to check the blood pressure of a patient who
is obese by using a standard-sized blood pressure cuff. The nurse should expect the reading
to:
a. Yield a falsely low blood pressure.
b. Yield a falsely high blood pressure.
c. Be the same, regardless of cuff size.
d. Vary as a result of the technique of the person performing the assessment.
ANS: B
Using a cuff that is too narrow yields a falsely high blood pressure because it takes extra
pressure to compress the artery.
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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.
[Link]
Physical Examination and Health Assessment CANADIAN 3rd Edition Jarvis Test Bank
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 blood pressure with the student in the supine position, which will allow him
to relax and will help obtain a more accurate reading.
ANS: A
When a person is comfortable and relaxed, a valid blood pressure can be obtained. 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.
DIF: Cognitive Level: Analyzing (Analysis)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
30. The nurse will perform palpation before auscultating blood pressure. The reason for this is
to:
a. More clearly hear Korotkoff’s sounds.
b. Detect the presence of an auscultatory gap.
c. Avoid missing a falsely elevated blood pressure.
d. More readily identify phase IV of Korotkoff’s sounds.
ANS: 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 Korotkoff’s sounds
disappear during auscultation.
N R I G B.C M
U S N T(Comprehension)
DIF: Cognitive Level: Understanding O
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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. The cuff should be placed on the patient’s arm and inflated 30 mm Hg above the
patient’s pulse rate.
b. The cuff should be inflated to 200 mm Hg in an attempt to obtain the most
accurate systolic reading.
c. The cuff should be inflated 30 mm Hg above the point at which the palpated pulse
disappears.
d. After confirming the patient’s previous blood pressure readings, the cuff should be
inflated 30 mm Hg above the highest systolic reading recorded.
ANS: C
An auscultatory gap occurs in approximately 5% of 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.
DIF: Cognitive Level: Analyzing (Analysis)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
[Link]
Physical Examination and Health Assessment CANADIAN 3rd Edition Jarvis Test Bank
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 mm Hg
b. 70 mm Hg
c. 80 mm Hg
d. 100 mm Hg
ANS: B
Pulse pressure is the difference between systolic and diastolic blood pressure (170 – 100 =
70 mm Hg) and reflects the stroke volume.
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Physiologic Integrity
33. When auscultating the blood pressure of a 25-year-old patient, the nurse notices that phase I
Korotkoff’s sounds begin at 200 mm Hg. At 100 mm Hg, Korotkoff’s sounds are muffled.
At 92 mm Hg, Korotkoff’s sounds disappear. How should the nurse record this patient’s
blood pressure?
a. 200/92 mm Hg
b. 200/100 mm Hg
c. 100/200/92 mm Hg
d. 200/100/92 mm Hg
ANS: A
In adults, the last audible sound best indicates the diastolic pressure. When a variance is
greater than 10 to 12 mm Hg between phases IV and V, both phases should be recorded
NUR(e.g.,
along with the systolic reading SIN142/98/80
[Link] M Hg).
DIF: Cognitive Level: Analyzing (Analysis)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
34. A patient is seen in the clinic for complaints of “fainting episodes that started last week.”
How should the nurse proceed with the examination?
a. Blood pressure readings are taken in both the arms and the thighs.
b. The patient is assisted to the lying position, and his blood pressure is taken.
c. His blood pressure is recorded in the lying, sitting, and standing positions.
d. His blood pressure is recorded in the lying and sitting positions; these numbers are
then averaged to obtain a mean blood pressure.
ANS: C
If the person is known to have hypertension, is taking antihypertensive medications, or
reports a history of fainting or syncope, then the blood pressure reading should be taken in
three positions: lying, sitting, and standing.
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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Physical Examination and Health Assessment CANADIAN 3rd Edition Jarvis Test Bank
35. A 70-year-old man has a blood pressure of 150/90 mm Hg in a lying position, 130/80 mm
Hg in a sitting position, and 100/60 mm Hg in a standing position. How should the nurse
evaluate these findings?
a. These readings are a normal response and attributable to changes in the patient’s
position.
b. The change in blood pressure readings is called orthostatic hypotension.
c. The blood pressure reading in the lying position is within normal limits.
d. The change in blood pressure readings is considered within normal limits for the
patient’s age.
ANS: B
Orthostatic hypotension is a greater than 20 mm Hg drop in systolic pressure, which occurs
with a quick change to the standing position. Older persons have the greatest risk for this
problem.
DIF: Cognitive Level: Analyzing (Analysis)
MSC: Client Needs: Health Promotion and Maintenance
36. The nurse is helping another nurse to take a blood pressure reading on a patient’s thigh.
Which action is correct regarding thigh pressure?
a. Either the popliteal or femoral vessels should be auscultated to obtain the thigh
blood pressure.
b. The best position to measure thigh blood pressure is the supine position with the
knee slightly bent.
c. If the arm blood pressure is high in an adolescent, then it should be compared with
the thigh blood pressure.
d. The thigh blood pressure NUisRlower
SINthan
GTB.C OMblood pressure, which is
the arm
attributable to the distance away from the heart and the size of the popliteal
vessels.
ANS: C
When blood pressure measured at the arm is excessively high, particularly in adolescents
and young adults, it is compared with the thigh blood pressure to check for coarctation of
the aorta. The popliteal artery is auscultated for the reading. Generally, the thigh blood
pressure is higher than arm blood pressure; however, if coarctation of the artery is present,
then the arm blood pressure will be higher than the thigh blood pressure.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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, followed by pulse and temperature.
b. Vital signs should be measured more frequently than in an adult.
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 familiarize the infant
and then measure the infant’s vital signs.
ANS: A
[Link]
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With an infant, the order of vital sign measurements is reversed, to respiration, pulse, and
temperature. Taking the temperature first, especially if it is by the rectal route, may cause
the infant to cry, which will increase the respiratory and pulse rates, thus masking the
normal resting values. The vital signs are measured with the same purpose and frequency as
would be in an adult.
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
38. A 4-month-old child is at the clinic for a well-baby checkup 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 observe 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 should be assessed by using a stethoscope with a large
diaphragm piece to hear soft, muffled Korotkoff’s sounds.
d. The infant’s chest should be observed and the respiratory rate counted for 1
minute; the respiratory pattern may vary significantly.
ANS: B
The nurse palpates or auscultates to detect the 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’s sounds with a stethoscope is difficult. The nurse should
use either an electronic blood pressure device that uses oscillometry or a Doppler ultrasound
[Link]
device to amplify the sounds.
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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 diastolic blood
pressures.
d. Changes in the body’s temperature regulatory mechanism are more likely to cause
fever to develop in the older person.
ANS: B
Aging causes a decrease in vital capacity and decreased inspiratory reserve volume. The
examiner may notice a shallower inspiratory phase and an increased respiratory rate. An
increase in the rigidity of the arterial walls makes the pulse actually easier to palpate. Pulse
pressure is widened in older adults, and changes in the body temperature regulatory
mechanism render the older person less likely to have fever but at a greater risk for
hypothermia.
DIF: Cognitive Level: Understanding (Comprehension)
[Link]
Physical Examination and Health Assessment CANADIAN 3rd Edition Jarvis Test Bank
MSC: Client Needs: Health Promotion and Maintenance
40. In a patient with acromegaly, the nurse will expect to discover which assessment findings?
a. Heavy, flattened facial features
b. Growth retardation and delayed onset of puberty
c. Overgrowth of bone in the face, head, hands, and feet
d. Increased height and weight and delayed sexual development
ANS: C
Excessive secretions of growth hormone in adulthood after normal completion of body
growth causes overgrowth of the bones in the face, head, hands, and feet but no change in
height.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
41. The nurse is performing a general survey of a patient. Which finding is considered normal?
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.
ANS: 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’s 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.
[Link]
DIF: Cognitive Level: Analyzing (Analysis)
MSC: Client Needs: Physiologic Integrity
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’s 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’s sounds can be used for the diastolic
reading in children.
ANS: D
The disappearance of phase V Korotkoff’s sounds can be used for the diastolic reading in
children and in adults.
DIF: Cognitive Level: Remembering (Knowledge)
MSC: Client Needs: Health Promotion and Maintenance
[Link]
Physical Examination and Health Assessment CANADIAN 3rd Edition Jarvis Test Bank
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.
ANS: C
If an auscultatory gap is undetected, then a falsely low systolic or falsely high diastolic
reading may result, and this is common in patients with hypertension.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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 into the tissues, averaged over the cardiac cycle.
d. MAP is an average of the systolic and diastolic blood pressures and reflects tissue
perfusion.
ANS: C
MAP is the pressure that forces blood into 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.
[Link]
DIF: Cognitive Level: Remembering (Knowledge)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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 right arm and then 5 minutes later on the left arm.
ANS: A
Orthostatic vital signs should be taken when the person is hypertensive or is taking
antihypertensive medications, when the person reports fainting or syncope, or when volume
depletion is suspected. The blood pressure and pulse readings are recorded in the supine,
sitting, and standing positions.
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
[Link]
Physical Examination and Health Assessment CANADIAN 3rd Edition Jarvis Test Bank
46. Which of these specific measurements is the best index of a child’s general health?
a. Vital signs
b. Height and weight
c. Head circumference
d. Chest circumference
ANS: B
Physical growth, measured by height and weight, is the best index of a child’s general
health.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Health Promotion and Maintenance
47. The nurse is assessing an 8-year-old child whose growth rate measures below the third
percentile for a child his age. He appears significantly younger than his stated age and is
chubby with infantile facial features. Which condition does this child have?
a. Hypopituitary dwarfism
b. Achondroplastic dwarfism
c. Marfan’s syndrome
d. Acromegaly
ANS: A
Hypopituitary dwarfism is caused by a deficiency in growth hormone in childhood and
results in a retardation of growth below the third percentile, delayed puberty, and other
problems. The child’s appearance fits this description. Achondroplastic dwarfism is a
genetic disorder resulting in characteristic deformities; Marfan’s syndrome is an inherited
NURSINGTbyB.C
connective tissue disorder characterized OMthin stature and other features.
a tall,
Acromegaly is the result of excessive secretion of growth hormone in adulthood. (For more
information, see Table 10-4, Abnormalities in Body Height and Proportion.)
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
48. The nurse is counting an infant’s respirations. Which technique is correct?
a. Watching the chest rise and fall
b. Watching the abdomen for movement
c. Placing a hand across the infant’s chest
d. Using a stethoscope to listen to the breath sounds
ANS: B
Watching the abdomen for movement is the correct technique because the infant’s
respirations are normally more diaphragmatic than thoracic. The other responses do not
reflect correct techniques.
DIF: Cognitive Level: Analyzing (Analysis)
MSC: Client Needs: Health Promotion and Maintenance
49. When checking for proper blood pressure cuff size, which guideline is correct?
a. The standard cuff size is appropriate for all sizes.
[Link]
Physical Examination and Health Assessment CANADIAN 3rd Edition Jarvis Test Bank
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.
ANS: 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.
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
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’s syndrome
b. Gigantism
c. Cushing’s syndrome
d. Acromegaly
ANS: C
Cushing’s 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, bruising, and acne. (See Table 10-4, Abnormalities in Body
Height and Proportion, for the definitions of the other conditions.)
DIF: Cognitive Level: Applying (Application)
NUREffective
MSC: Client Needs: Safe and [Link]:
OM Management of Care
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 at the 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.
ANS: A, B, D, E
Several factors can result in blood pressure readings that are falsely high or low. Most of the
options will result in falsely high readings. Not inflating the cuff high enough or poor
inflation of the cuff result in a falsely low systolic. Having the patient’s arm held at the level
of the heart is one part of the correct technique. (Refer to Table 10-3, Common Errors in
Blood Pressure Measurement.)
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
[Link]
Physical Examination and Health Assessment CANADIAN 3rd Edition Jarvis Test Bank
SHORT ANSWER
1. What is the pulse pressure for a patient whose blood pressure is 158/96 mm Hg and pulse
rate is 72 beats per minute?
ANS:
62
The pulse pressure is the difference between the systolic and diastolic pressures and reflects
the stroke volume. The pulse rate is not necessary for pulse pressure calculations.
DIF: Cognitive Level: Analyzing (Analysis)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
[Link]
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