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Nursing
Q:
A 50-year-old woman with elevated total cholesterol and triglyceride levels is visiting the clinic to find out about her laboratory results. What would be important for the nurse to include in patient teaching in relation to these tests?
a. The risks of undernutrition should be included.
b. Offer methods to reduce the stress in her life.
c. Provide information regarding a diet low in saturated fat.
d. This condition is hereditary; she can do nothing to change the levels.
Q:
The nurse is evaluating patients for obesity-related diseases by calculating the waist-to-hip ratios. Which one of these patients would be at increased risk?
a. 29-year-old woman whose waist measures 33 inches and hips measure 36 inches
b. 32-year-old man whose waist measures 34 inches and hips measure 36 inches
c. 38-year-old man whose waist measures 35 inches and hips measure 38 inches
d. 46-year-old woman whose waist measures 30 inches and hips measure 38 inches
Q:
In teaching a patient how to determine total body fat at home, the nurse includes instructions to obtain measurements of:
a. Height and weight.
b. Frame size and weight.
c. Waist and hip circumferences.
d. Mid-upper arm circumference and arm span.
Q:
How should the nurse perform a triceps skinfold assessment?
a. After pinching the skin and fat, the calipers are vertically applied to the fat fold.
b. The skin and fat on the front of the patient's arm are gently pinched, and then the calipers are applied.
c. After applying the calipers, the nurse waits 3 seconds before taking a reading. After repeating the procedure three times, an average is recorded.
d. The patient is instructed to stand with his or her back to the examiner and arms folded across the chest. The skin on the forearm is pinched.
Q:
If a 29-year-old woman weighs 156 pounds, and the nurse determines her ideal body weight to be 120 pounds, then how would the nurse classify the woman's weight?
a. Obese
b. Mildly overweight
c. Suffering from malnutrition
d. Within appropriate range of ideal weight
Q:
When considering a nutritional assessment, the nurse is aware that the most common anthropometric measurements include:
a. Height and weight.
b. Leg circumference.
c. Skinfold thickness of the biceps.
d. Hip and waist measurements.
Q:
The nurse is reviewing the nutritional assessment of an 82-year-old patient. Which of these factors will most likely affect the nutritional status of an older adult?
a. Increase in taste and smell
b. Living alone on a fixed income
c. Change in cardiovascular status
d. Increase in gastrointestinal motility and absorption
Q:
The nurse is discussing appropriate foods with the mother of a 3-year-old child. Which of these foods are recommended?
a. Foods that the child will eat, no matter what they are
b. Foods easy to hold such as hot dogs, nuts, and grapes
c. Any foods, as long as the rest of the family is also eating them
d. Finger foods and nutritious snacks that cannot cause choking
Q:
The nurse is performing a nutritional assessment on a 15-year-old girl who tells the nurse that she is "so fat." Assessment reveals that she is 5 feet 4 inches and weighs 110 pounds. The nurse's appropriate response would be:
a. "How much do you think you should weigh?"
b. "Don"t worry about it; you"re not that overweight."
c. "The best thing for you would be to go on a diet."
d. "I used to always think I was fat when I was your age."
Q:
A patient tells the nurse that his food simply does not have any taste anymore. The nurse's best response would be:
a. "That must be really frustrating."
b. "When did you first notice this change?"
c. "My food doesn"t always have a lot of taste either."
d. "Sometimes that happens, but your taste will come back."
Q:
During a nutritional assessment, why is it important for the nurse to ask a patient what medications he or she is taking?
a. Certain drugs can affect the metabolism of nutrients.
b. The nurse needs to assess the patient for allergic reactions.
c. Medications need to be documented in the record for the physician's review.
d. Medications can affect one's memory and ability to identify food eaten in the last 24 hours.
Q:
The nurse is providing care for a 68-year-old woman who is complaining of constipation. What concern exists regarding her nutritional status?
a. Absorption of nutrients may be impaired.
b. Constipation may represent a food allergy.
c. The patient may need emergency surgery to correct the problem.
d. Gastrointestinal problems will increase her caloric demand.
Q:
A patient is asked to indicate on a form how many times he eats a specific food. This method describes which of these tools for obtaining dietary information?
a. Food diary
b. Calorie count
c. 24-hour recall
d. Food-frequency questionnaire
Q:
For the first time, the nurse is seeing a patient who has no history of nutrition-related problems. The initial nutritional screening should include which activity?
a. Calorie count of nutrients
b. Anthropometric measures
c. Complete physical examination
d. Measurement of weight and weight history
Q:
The nurse is assessing a 30-year-old unemployed immigrant from an underdeveloped country who has been in the United States for 1 month. Which of these problems related to his nutritional status might the nurse expect to find?
a. Obesity
b. Hypotension
c. Osteomalacia (softening of the bones)
d. Coronary artery disease
Q:
A mother and her 13-year-old daughter express their concern related to the daughter's recent weight gain and her increase in appetite. Which of these statements represents information the nurse should discuss with them?
a. Dieting and exercising are necessary at this age.
b. Snacks should be high in protein, iron, and calcium.
c. Teenagers who have a weight problem should not be allowed to snack.
d. A low-calorie diet is important to prevent the accumulation of fat.
Q:
A pregnant woman is interested in breastfeeding her baby and asks several questions about the topic. Which information is appropriate for the nurse to share with her?
a. Breastfeeding is best when also supplemented with bottle feedings.
b. Babies who are breastfed often require supplemental vitamins.
c. Breastfeeding is recommended for infants for the first 2 years of life.
d. Breast milk provides the nutrients necessary for growth, as well as natural immunity.
Q:
The nurse is providing nutrition information to the mother of a 1-year-old child. Which of these statements represents accurate information for this age group?
a. Maintaining adequate fat and caloric intake is important for a child in this age group.
b. The recommended dietary allowances for an infant are the same as for an adolescent.
c. The baby's growth is minimal at this age; therefore, caloric requirements are decreased.
d. The baby should be placed on skim milk to decrease the risk of coronary artery disease when he or she grows older.
Q:
When assessing a patient's nutritional status, the nurse recalls that the best definition of optimal nutritional status is sufficient nutrients that:
a. Are in excess of daily body requirements.
b. Provide for the minimum body needs.
c. Provide for daily body requirements but do not support increased metabolic demands.
d. Provide for daily body requirements and support increased metabolic demands.
Q:
The nurse recognizes which of these persons is at greatest risk for undernutrition?
a. 5-month-old infant
b. 50-year-old woman
c. 20-year-old college student
d. 30-year-old hospital administrator
Q:
During an admission assessment of a patient with dementia, the nurse assesses for pain because the patient has recently had several falls. Which of these are appropriate for the nurse to assess in a patient with dementia? Select all that apply.
a. Ask the patient, "Do you have pain?"
b. Assess the patient's breathing independent of vocalization.
c. Note whether the patient is calling out, groaning, or crying.
d. Have the patient rate pain on a 1-to-10 scale.
e. Observe the patient's body language for pacing and agitation.
Q:
During assessment of a patient's pain, the nurse is aware that certain nonverbal behaviors are associated with chronic pain. Which of these behaviors are associated with chronic pain? Select all that apply.
a. Sleeping
b. Moaning
c. Diaphoresis
d. Bracing
e. Restlessness
f. Rubbing
Q:
A patient has been admitted to the hospital with vertebral fractures related to osteoporosis. She is in extreme pain. This type of pain would be classified as:
a. Referred.
b. Cutaneous.
c. Visceral.
d. Deep somatic.
Q:
The nurse knows that which statement is true regarding the pain experienced by infants?
a. Pain in infants can only be assessed by physiologic changes, such as an increased heart rate.
b. The FPS-R can be used to assess pain in infants.
c. A procedure that induces pain in adults will also induce pain in the infant.
d. Infants feel pain less than do adults.
Q:
A patient is complaining of severe knee pain after twisting it during a basketball game and is requesting pain medication. Which action by the nurse is appropriate?
a. Completing the physical examination first and then giving the pain medication
b. Telling the patient that the pain medication must wait until after the x-ray images are completed
c. Evaluating the full range of motion of the knee and then medicating for pain
d. Administering pain medication and then proceeding with the assessment
Q:
When assessing the intensity of a patient's pain, which question by the nurse is appropriate?
a. "What makes your pain better or worse?"
b. "How much pain do you have now?"
c. "How does pain limit your activities?"
d. "What does your pain feel like?"
Q:
The nurse is reviewing the principles of nociception. During which phase of nociception does the conscious awareness of a painful sensation occur?
a. Perception
b. Modulation
c. Transduction
d. Transmission
Q:
When assessing a patient's pain, the nurse knows that an example of visceral pain would be:
a. Hip fracture.
b. Cholecystitis.
c. Second-degree burns.
d. Pain after a leg amputation.
Q:
When assessing the quality of a patient's pain, the nurse should ask which question?
a. "When did the pain start?"
b. "Is the pain a stabbing pain?"
c. "Is it a sharp pain or dull pain?"
d. "What does your pain feel like?"
Q:
The nurse is reviewing the principles of pain. Which type of pain is due to an abnormal processing of the pain impulse through the peripheral or central nervous system?
a. Visceral
b. Referred
c. Cutaneous
d. Neuropathic
Q:
A patient has had arthritic pain in her hips for several years since a hip fracture. She is able to move around in her room and has not offered any complaints so far this morning. However, when asked, she states that her pain is "bad this morning" and rates it at an 8 on a 1-to-10 scale. What does the nurse suspect? The patient:
a. Is addicted to her pain medications and cannot obtain pain relief.
b. Does not want to trouble the nursing staff with her complaints.
c. Is not in pain but rates it high to receive pain medication.
d. Has experienced chronic pain for years and has adapted to it.
Q:
The nurse is assessing a patient's pain. The nurse knows that the most reliable indicator of pain would be the:
a. Patient's vital signs.
b. Physical examination.
c. Results of a computerized axial tomographic scan.
d. Subjective report.
Q:
A 60-year-old woman has developed reflexive sympathetic dystrophy after arthroscopic repair of her shoulder. A key feature of this condition is that the:
a. Affected extremity will eventually regain its function.
b. Pain is felt at one site but originates from another location.
c. Patient's pain will be associated with nausea, pallor, and diaphoresis.
d. Slightest touch, such as a sleeve brushing against her arm, causes severe and intense pain.
Q:
A patient states that the pain medication is "not working" and rates his postoperative pain at a 10 on a 1-to-10 scale. Which of these assessment findings indicates an acute pain response to poorly controlled pain?
a. Confusion
b. Hyperventilation
c. Increased blood pressure and pulse
d. Depression
Q:
A 4-year-old boy is brought to the emergency department by his mother. She says he points to his stomach and says, "It hurts so bad." Which pain assessment tool would be the best choice when assessing this child's pain?
a. Descriptor Scale
b. Numeric rating scale
c. Brief Pain Inventory
d. Faces Pain ScaleRevised (FPS-R)
Q:
Which statement indicates that the nurse understands the pain experienced by an older adult?
a. "Older adults must learn to tolerate pain."
b. "Pain is a normal process of aging and is to be expected."
c. "Pain indicates a pathologic condition or an injury and is not a normal process of aging."
d. "Older individuals perceive pain to a lesser degree than do younger individuals."
Q:
When evaluating a patient's pain, the nurse knows that an example of acute pain would be:
a. Arthritic pain.
b. Fibromyalgia.
c. Kidney stones.
d. Low back pain.
Q:
What is the pulse pressure for a patient whose blood pressure is 158/96 mm Hg and whose pulse rate is 72 beats per minute?
Q:
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 above 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.
Q:
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 syndrome
b. Gigantism
c. Cushing syndrome
d. Acromegaly
Q:
When checking for proper blood pressure cuff size, which guideline is correct?
a. The standard cuff size is appropriate for all sizes.
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.
Q:
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
Q:
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 syndrome
d. Acromegaly
Q:
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
Q:
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.
Q:
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.
Q:
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.
Q:
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 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 sounds can be used for the diastolic reading in children.
Q:
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.
Q:
In a patient with acromegaly, the nurse will expect to discover which assessment findings?
a. Heavy, flattened facial features
b. Growth retardation and a delayed onset of puberty
c. Overgrowth of bone in the face, head, hands, and feet
d. Increased height and weight and delayed sexual development
Q:
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 leave the older person more likely to develop a fever.
Q:
A 4-month-old child is at the clinic for a well-baby check-up 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 notice 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 the soft muffled Korotkoff sounds.
d. The infant's chest should be observed and the respiratory rate counted for 1 minute; the respiratory pattern may vary significantly.
Q:
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; then 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 allow the infant to become more familiar with her and then measure the infant's vital signs.
Q:
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 a thigh pressure.
b. The best position to measure thigh pressure is the supine position with the knee slightly bent.
c. If the blood pressure in the arm is high in an adolescent, then it should be compared with the thigh pressure.
d. The thigh pressure is lower than the pressure in the arm, which is attributable to the distance away from the heart and the size of the popliteal vessels.
Q:
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.
Q:
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 a 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.
Q:
When auscultating the blood pressure of a 25-year-old patient, the nurse notices the phase I Korotkoff sounds begin at 200 mm Hg. At 100 mm Hg, the Korotkoff sounds muffle. At 92 mm Hg, the Korotkoff sounds disappear. How should the nurse record this patient's blood pressure?
a. 200/92
b. 200/100
c. 100/200/92
d. 200/100/92
Q:
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
b. 70
c. 80
d. 100
Q:
The nurse is taking an initial blood pressure reading on a 72-year-old patient with documented hypertension. How should the nurse proceed?
a. Cuff should be placed on the patient's arm and inflated 30 mm Hg above the patient's pulse rate.
b. Cuff should be inflated to 200 mm Hg in an attempt to obtain the most accurate systolic reading.
c. 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.
Q:
The nurse will perform a palpated pressure before auscultating blood pressure. The reason for this is to:
a. More clearly hear the Korotkoff sounds.
b. Detect the presence of an auscultatory gap.
c. Avoid missing a falsely elevated blood pressure.
d. More readily identify phase IV of the Korotkoff sounds.
Q:
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.
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 his blood pressure in the supine position, which will provide a more accurate reading and will allow him to relax at the same time.
Q:
The nurse notices 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.
Q:
A nurse is helping at a health fair at a 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 taken in men.
b. The blood pressure of a Black adult is usually higher than that of a White adult 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.
Q:
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
c. Vascular output
d. Peripheral vascular resistance
Q:
A patient's blood pressure is 118/82 mm Hg. He asks the nurse, "What do the numbers mean?" The nurse's best reply is:
a. "The numbers are within the normal range and are 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."
Q:
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.
Q:
The nurse is assessing the vital signs of a 20-year-old male marathon runner and documents the following vital signs: temperature"36o 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.c. The patient's pulse rate is not normalhis physician should be notified.d. On the basis of these readings, the patient should return to the clinic in 1 week.
Q:
When assessing the force, or strength, of a pulse, the nurse recalls that the pulse:
a. Is usually recorded on a 0- to 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.
Q:
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.
Q:
When assessing a patient's pulse, the nurse should also notice which of these characteristics?
a. Force
b. Pallor
c. Capillary refill time
d. Timing in the cardiac cycle
Q:
Which technique is correct when the nurse is assessing the radial pulse of a patient?
The pulse is counted for:
a. 1 minute, if the rhythm is irregular.
b. 15 seconds and then multiplied by 4, if the rhythm is regular.
c. 2 full minutes to detect any variation in amplitude.
d. 10 seconds and then multiplied by 6, if the patient has no history of cardiac abnormalities.
Q:
To assess a rectal temperature accurately in an adult, the nurse would:
a. Use a lubricated blunt tip thermometer.
b. Insert the thermometer 2 to 3 inches into the rectum.
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.
Q:
The nurse is taking temperatures in a clinic with a TMT. Which statement is true regarding use of the TMT?
a. A tympanic temperature is more time consuming than a rectal temperature.
b. The tympanic method is more invasive and uncomfortable than the oral method.
c. The risk of cross-contamination is reduced, compared with the rectal route.
d. The tympanic membrane most accurately reflects the temperature in the ophthalmic artery.
Q:
Which of these actions illustrates the correct technique the nurse should use when assessing oral temperature with a mercury thermometer?
a. Wait 30 minutes if the patient has ingested hot or iced liquids.
b. Leave the thermometer in place 3 to 4 minutes if the patient is afebrile.
c. Place the thermometer in front of the tongue, and ask the patient to close his or her lips.
d. Shake the mercury-in-glass thermometer down to below 36.6 C before taking the temperature.
Q:
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:
a. Assume that the patient is eager and interested in participating in the interview.
b. Evaluate the patient for abdominal pain, which may be exacerbated in the sitting position.
c. Assume that the patient is having difficulty breathing and assist him to a supine position.
d. Recognize that a tripod position is often used when a patient is having respiratory difficulties.
Q:
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:
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.
Q:
When evaluating the temperature of older adults, the nurse should remember which aspect about an older adult's body temperature?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.
Q:
When measuring a patient's body temperature, the nurse keeps in mind that body temperature is influenced by:
a. Constipation.
b. Patient's emotional state.
c. Diurnal cycle.
d. Nocturnal cycle.
Q:
The nurse is examining a patient who is complaining of "feeling cold." Which is a mechanism of heat loss in the body?
a. Exercise
b. Radiation
c. Metabolism
d. Food digestion
Q:
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
d. Decrease in diastolic blood pressure