Jamiatu Dansalan Al-Islamia Foundation Inc.

nd
2 Floor JIMS Café, Panggao Saduc, Marawi City
COLLEGE DEPARTMENT
SY: 2024

ACTIVITY II
NAME: ____________________________________ SECTION & YEAR: __________ SCORE: _______
MULTIPLE CHOICE: CIRCLE THE BEST ANSWER

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

2. When measuring a patient's weight, the nurse keeps in mind which of these guidelines?
A) Always weigh the patient with only his or her undergarments on.
B) It does not matter what type of scale is used, 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 this is documented next to the weight.
D) Attempt to weigh the patient at approximately the same time of day, if a sequence of weights is necessary.

3. 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.

4. The nurse should measure rectal temperatures in which of these patients?

A) School-age child
B) Elderly adult
C) Comatose adult
D) Patient receiving oxygen by nasal cannula

5. The nurse is preparing to measure the length, weight, chest, and head circumference of a 6-month-old infant. Which
measurement technique is correct?
A) Measure the infant's length by using a tape measure.
B) Weigh the infant by placing him on an electronic standing scale.
C) Measure chest circumference at the nipple line with a tape measure.
D) Measure the head circumference by wrapping the tape measure over the nose and cheekbones.

6. The nurse knows that one advantage of the tympanic thermometer is that:
A) Its rapid measurement is useful for uncooperative younger children.
B) It is the most accurate method for measuring temperature in newborn infants.
C) It is an inexpensive means of measuring temperature.
D) Studies strongly support use of the tympanic route in children under age 6 years.

7. When assessing an older adult, the nurse keeps in mind that 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

8. 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
9. 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) The diurnal cycle.
D) The nocturnal cycle.

10. When evaluating the temperature of older adults, the nurse remembers which aspect about an older adult's body
temperature?
A) It is lower than that of younger adults.
B) It is about the same as that of a young child.
C) It depends on the type of thermometer used.
D) It varies widely because of less effective heat control mechanisms.

11. 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 have the patient close his or her lips.
D) Shake the mercury-in-glass thermometer down to 98° F before taking the temperature.

12. The nurse is taking temperatures in a clinic with a tympanic thermometer. Which statement is true regarding use of
the tympanic thermometer?
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) There is a reduced risk of cross-contamination compared with the rectal route.
D) The tympanic membrane most accurately reflects the temperature in the ophthalmic artery.

14. To accurately assess a rectal temperature on 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.

15. Which technique is correct when the nurse is assessing the radial pulse of a patient? Count the:
A) Pulse for 1 minute if the rhythm is irregular.
B) Pulse for 15 seconds and multiply by four, if the rhythm is regular.
C) Initial pulse for a full 2 minutes to detect any variation in amplitude.
D) Pulse for 10 seconds and multiply by six, if the patient has no history of cardiac abnormalities.

16. 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

17. When assessing the force, or strength, of a pulse, the nurse recalls that it:
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.

18. The nurse is assessing the vital signs of a 20-year-old male marathon runner and documents the following vital signs:
temperature—97 F; pulse—48 beats per minute; respirations—14 per minute; blood pressure—104/68 mm Hg. Which
statement is true about 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 normal—his physician should be notified.
D) On the basis of today's readings, the patient should return to the clinic in 1 week.
19. 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) Count the respirations for 1 full minute, noticing rate and rhythm.
B) Check the child's pulse and respirations simultaneously for 30 seconds.
C) Check the child's respirations for a minimum of 5 minutes to identify any variations in respiratory pattern.
D) Count the patient's respirations for 15 seconds and multiply by four to obtain the number of respirations per minute.

20. A patient's blood pressure is 118/82. He asks the nurse to explain "what the numbers mean." The nurse's best reply
would be:
A) "The numbers are within 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 main thing to be concerned about is the top number, or
systolic blood pressure."

21. While measuring a patient's blood pressure, the nurse recalls that certain factors help to determine blood pressure,
such as:
A) Pulse rate.
B) Pulse pressure.
C) Vascular output.
D) Peripheral vascular resistance.

22. 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:
A) After menopause, blood pressure in women is usually lower than in men.
B) A black adult's blood pressure is usually higher than that of whites 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 teen's blood pressure reading will be lower than that of an adult.

23. 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.

24. The nurse will perform a palpated pressure before auscultating blood pressure. The reason for this is to:
A) Hear the Korotkoff sounds more clearly.
B) Detect the presence of an auscultatory gap.
C) Avoid missing a falsely elevated blood pressure.
D) Identify phase IV of the Korotkoff sounds more readily.

25. The nurse has collected the following information on a patient: palpated blood pressure—180; auscultated blood
pressure—170/100 mm Hg; apical pulse—60; radial pulse—70. What is the patient's pulse pressure?
A) 10
B) 70
C) 80
D) 100

26. Patient is being seen in the clinic for complaints of "fainting episodes that started last week." How should the nurse
proceed with the examination?
A) Take his blood pressure in both arms and thighs.
B) Assist him to a lying position and begin taking his blood pressure.
C) Record his blood pressure in the lying, sitting, and standing positions.
D) Record his blood pressure in the lying and sitting positions and average these numbers. To obtain a mean blood
pressure.
27. 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) This is a normal response due 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 reading is considered within normal limits for the patient's age.

28. He nurse is helping another nurse to take a blood pressure reading on a patient's thigh. Which action is correct
regarding thigh pressure?
A) Auscultate either the popliteal or femoral vessels 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 compare it with the thigh pressure.
D) The thigh pressure is lower than that in the arm due to distance away from the heart and the size of the popliteal
vessels.

29. 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 systolic and diastolic blood pressures.
D) Changes in the body's temperature regulatory mechanism leave the aging person more likely to develop a fever.

30. 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) The diastolic blood pressure may not be heard.
B) The diastolic blood pressure may be falsely low.
C) The systolic blood pressure may be falsely low.
D) The systolic blood pressure may be falsely high.