Physical Assessment Q&A

CHAPTER 7: Assessing General Health Status and Vital Signs

CHAPTER 7: Assessing General Health Status and Vital Signs

A.

1. The nurse is preparing to assess an adult client in the clinic. The nurse observes that the

client is wearing lightweight clothing although the temperature is below freezing outside.

The nurse anticipates that the client may be

a. abusing drugs.

b. a victim of abuse.

c. lacking adequate finances.

d. anxious.

2. An elderly client is seen by the nurse in the neighborhood clinic. The nurse observes that the

client is dressed in several layers of clothing, although the temperature is warm outside. The

nurse suspects that the client's cold intolerance is a result of

a. decreased body metabolism.

b. neurologic deficits.

c. recent surgery.

d. pancreatic disease.

B.

1. The nurse is assessing an elderly postsurgical client in the home. To begin the physical examination,

the nurse should first assess the client's

a. height and weight.

b. ability to swallow.

c. vital signs.

d. gait.

2. While caring for an 80-year-old client in his home, the nurse determines that the client's

temperature is 96.5F. The nurse determines that the client is most likely exhibiting

a. normal changes that occur with the aging process.

b. hypothermia that occurs before an infectious process.

c. a metabolic disorder resulting in circulatory changes.

d. an immune disorder resulting in low platelet count.

3. The nurse is preparing to assess the respirations of an alert adult client. The nurse should

a. explain to the client that he or she will be counting the client's respirations.

b. observe for equal bilateral chest expansion of 1 to 2 inches.

c. count for 15 seconds and multiply the number by 4 to obtain the rate.

d. ask the client to lie in a supine position, which makes counting the respirations easier.

4. While assessing an older adult client's respirations, the nurse can anticipate that the respiratory

pattern may exhibit a

a. shorter inspiratory phase.

b. longer inspiratory phase.

c. shorter expiratory phase.

d. longer expiratory phase.

5. The nurse is caring for a client who is having nothing by mouth (NPO) on the first postoperative

day. The client's blood pressure was 120/80 mm Hg approximately 4 hours ago, but it is

now 140/88 mm Hg. The nurse should ask the client which of the following questions?

a. "Are you taking any medications for hypertension?"

b. "Do you have enough blankets to stay warm?"

c. "Are you having pain from your surgery?"

d. "What is your typical blood pressure reading?"

6. A normal pulse pressure range for an adult client is typically

a. 20 to 40 mm Hg.

b. 30 to 50 mm Hg.

c. 40 to 60 mm Hg.

d. 60 to 80 mm Hg.