HA Chapter 9

HA Chapter 9

• The nurse is performing a general survey. Which action is a component of the general

survey?:

Answer Observing the patient's body stature and nutritional status

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

2. Observing the patient's body stature and nutritional status:

Answer Attempt to weigh the patient at approximately the same time of day, if a sequence of weights is necessary.

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 aim for approximately the same time of day and type of clothing worn each time.

• A patient's weekly blood pressure readings for 2 months have ranged between 124/84

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?:

Answer Prehypertension

According to the JNC-VII guidelines, prehypertension blood pressure readings are systolic 120 to 139 mm Hg or diastolic 50 to 89 mm Hg.

• During an examination of a child, the nurse considers that physical growth is the best

index of a child's::

Answer general health.

Physical growth is the best index of a child's general health; recording the child's height and weight help to determine normal growth patterns.

• A 1-month-old infant has a head measurement of 34 cm and has a chest circumference

of 32 cm. Based on interpretation of these findings, the nurse would::

Answer consider this a normal finding for a 1-month-old infant.

The newborn's head measures about 32 to 38 cm and is about 2 cm larger than the chest circumference. Between 6 months and 2 years, both measurements are about the same, and after age 2 years, the chest circumference is greater than the head circumference.

• The nurse is assessing an 80-year-old male patient. Which assessment findings would

be considered normal?:

Answer The presence of kyphosis and flexion in the knees and hips

Changes that occur in the aging person include more prominent bony landmarks, decreased body weight (especially in males), 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.

• The nurse should measure rectal temperatures in which of these patients?-

Answer Comatose adult

Rectal temperatures should be taken when the other routes are not practical, such as for comatose or confused persons, for persons in shock, or for those who cannot close the mouth because of breathing or oxygen tubes, wired mandible, or other facial dysfunctions.

• The nurse is preparing to measure the length, weight, chest, and head circumference of

a 6-month-old infant. Which measurement technique is correct?:

Answer Measure chest circumference at the nipple line with a tape measure.

To measure chest circumference, encircle the tape around the chest at the nipple line.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, at the prominent frontal and occipital bones; the widest span is correct.

9. The nurse knows that one advantage of the tympanic thermometer is that:-

Answer its rapid measurement is useful for uncooperative younger children.

The tympanic thermometer (TMT) is useful for younger children who may not cooperate for oral temperatures and fear rectal temperatures. Keep in mind that TMT use with newborn infants and young children is conflicting.

• When assessing an older adult, the nurse keeps in mind that which vital sign changes

occur with aging?:

Answer Widened pulse pressure

With aging 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.

• The nurse is examining a patient who is complaining of "feeling cold." Which is a

mechanism of heat loss in the body?:

Answer Radiation

The body maintains a steady temperature through a thermostat, or feedback mechanism, 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).

• When measuring a patient's body temperature, the nurse keeps in mind that body

temperature is influenced by::

Answer the diurnal cycle.

Normal temperature is influenced by the diurnal cycle, exercise, and age. The other responses do not influence body temperature.

• When evaluating the temperature of older adults, the nurse remembers which aspect

about an older adult's body temperature?:

Answer It is lower than that of younger adults.

In older adults, temperature is usually lower than in other age groups, with a mean temperature of 36.2° C (97.2° F).

• A 60-year-old male patient has been treated for pneumonia for the past 6 weeks. He

is seen today in the clinic for an "unexplained" weight loss of 10 pounds over the last 6 weeks. The nurse knows that::

Answer unexplained weight loss often accompanies short-term illnesses.

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.

• When assessing a 75-year-old patient who has asthma, the nurse notes that he

assumes a tripod position, leaning forward with arms braced on the chair. On the basis of this observation, the nurse should::

Answer recognize that a tripod position is often used when a patient is having respiratory difficulties.

Assuming a tripod position—leaning forward with arms braced on chair arms—occurs with chronic pulmonary disease. The other actions or assumptions are not correct.

• Recognize that a tripod position is often used when a patient is having respiratory

difficulties.:

Answer Leave the thermometer in place 3 to 4 minutes if the patient is afebrile.

Leave the thermometer in place 3 to 4 minutes if the person is afebrile and up to 8 minutes if the person is febrile. Wait 15 minutes if the person has just taken hot or iced liquids and

• minutes if he or she has just smoked.

• The nurse is taking temperatures in a clinic with a tympanic thermometer. Which

statement is true regarding use of the tympanic thermometer?:

Answer There is a reduced risk of cross-contamination compared with the rectal route.

The tympanic membrane thermometer is a noninvasive, no traumatic device that is extremely quick and efficient. There is minimal chance of cross-contamination with the tympanic thermometer because the ear canal is lined with skin, not mucous membrane.

• To accurately assess a rectal temperature on an adult, the nurse would:: -