General survey and vital signs Quiz

All of the following equipment is used to perform a physical health assessment EXCEPT:

• A sphygmomanometer.

• A watch or clock with a second hand.

• A stethoscope.

• A body mass index (BMI) chart.

Blood pressure is measured routinely as part of the vital sign assessment. The best sites that a blood pressure can be taken include all of the following EXCEPT:

• The ankle.

• The upper arm.

• The forearms.

• The thigh.

A patient arrives for a physical assessment and is complaining of not feeling well. The nurse begins with a general survey and assessing vital signs. The nurse is concerned that the patient has orthostatic hypotension due to the patient complaining of:

• Alteration in mental status and forgetfulness.

• Dizziness and feeling lightheaded with position changes.

• Gastrointestinal upset, nausea, and vomiting.

• Feeling cold, weak, and shivering.

When assessing a patient’s vital signs, a nurse understands that an essential principle of vital sign assessment is:

• Retaking the vital signs if the first set is not within normal range.

• Comparing a patient’s baseline or prior vital signs to the current reading.

• Asking the patient if he or she remembers the last set of vital signs.

• There is no need to compare current vital signs to previous vital signs.

You are caring for a patient with traumatic brain injury. The healthcare provider has ordered rectal temperatures daily. How far should you insert the rectal probe into the anal canal?

• About 0.50 inch

• About 0.75 inch

• About 1.0 inch

Measuring a patient’s body temperature is part of routine essential nursing care and can be taken in several different ways. The site and measuring device is chosen based on a number of factors including which of the following? Select all that apply.

• Patient preference

• Age of patient

• Mental status and cognition

• Physical condition of patient

• Safety and nurse’s technique with using device

Hypertension is a growing health problem in the United States. Which of the following factors can affect blood pressure? Select all that apply.

• Obesity

• Family history

• Alcohol consumption of three or more drinks per day

• Stress

• Diets high in magnesium

You are preparing to assess a patient’s blood pressure. You start by wrapping the deflated cuff around the patient’s arm about (a)   inch(es) above the brachial artery.

You are assessing the radial pulse and determine that it is 92 and irregular. You auscultate the apical pulse at 104 and irregular. What is the pulse deficit? (a)  

It is not necessary to wait to perform an oral temperature on a patient who is able to understand and follow directions.

• This is incorrect. It is not necessary to wait to perform an oral temperature on a patient who is able to understand and follow directions.

• This is incorrect. It is not necessary to wait to perform an oral temperature on a patient who is able to breathe through the nose.

• This is incorrect. It is not necessary to wait to perform an oral temperature on a patient who has an abnormal mental status; however, you may choose a different route to take the temperature.

• This is correct. If a patient has consumed or drank hot or cold foods or beverages, it is important to wait 30 minutes to take an oral temperature in order to obtain an accurate temperature reading.