Chapter 09: General Survey, Measurement, Vital Signs

Chapter 09: General Survey, Measurement, Vital Signs

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

MULTIPLE CHOICE

 

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

 

 

ANS:  A

The general survey is a study of the whole person that includes observing the patient’s physical appearance, body structure, mobility, and behavior.

 

DIF:    Cognitive Level: Understanding (Comprehension)             REF:   p. 127

MSC:  Client Needs: Safe and Effective Care Environment: Management of Care

 

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.
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.

 

 

ANS:  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.

 

DIF:    Cognitive Level: Understanding (Comprehension)             REF:   p. 129

MSC:  Client Needs: Safe and Effective Care Environment: Management of Care

 

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

 

 

ANS:  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.

 

DIF:    Cognitive Level: Understanding (Comprehension)             REF:   p. 159

MSC:  Client Needs: Safe and Effective Care Environment: Management of Care

 

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.

 

 

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)                    REF:   p. 146

MSC:  Client Needs: Health Promotion and Maintenance

 

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.

 

 

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.

 

DIF:    Cognitive Level: Analyzing (Analysis)                              REF:   p. 147

MSC:  Client Needs: Health Promotion and Maintenance