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Health Assessment Exam 1 C Questions and Answers 100% Solved
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Health Assessment Exam 1 C
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Health Assessment Exam 1 CA nurse is taking an adult client's temperature rectally. Which of the following actions
should the nurse take?
- Rotate the probe if any resistance is met as the thermometer is inserted.
- Insert the probe to aim at the client's pelvic area.
- Dip the probe about 0.58 cm (2in) into a tube of lubricant.
- Insert the probe about 2.5 cm (1in) into the clients anus. - answerInsert the probe
about 2.5 cm (1in) into the clients anus.
An insertion depth of 2.5 to 3.5 cm (1 to 1.5 in) for an adult ensures sufficient exposure
of the probe to the blood vessels in the rectal wall. Positioning the probe against the
blood vessels enables it to measure heat maximally and accurately.
A nurse is obtaining a client's blood pressure and notices the pressure reading on the
manometer when listening to the fourth Korotkoff sound. Which of the following factors
does this pressure reading correlate to?
- It corresponds to the client's systolic pressure.
- It is the second diastolic pressure to record.
- It is the loudest of the Korotkoff sounds.
- It might not follow with a fifth Korotkoff sound. - answerIt might not follow with a fifth
Korotkoff sound.
Most clinicians consider the fifth Korotkoff sound, which is actually the disappearance of
sound, as an adult client's diastolic blood pressure. However, with some clients, there is
no distinct fifth sound. You hear sounds all the way to 0 mm Hg. For these clients, the
nurse should record the fourth Korotkoff sound as the diastolic blood pressure.
A nurse is preparing to auscultate a clients apical pulse at the point of maximal impulse
(PMI). In which of the following locations should,d the nurse position the stethoscope?
- Over the right midclavicular line
- Over the angle of Louis
- Overt the fifth intercostal space at the left midclavicular line
- Over the suprasternal notch - answerOvert the fifth intercostal space at the left
midclavicular line
To locate the PMI, the nurse should first locate the angle of Louis, a bony prominence
just below the suprasternal notch. The nurse should then slide their fingers down each
side of the angle of Louis to locate the second intercostal space. Next, the nurse should
,gently move their fingers down the left side of the sternum to the fifth intercostal space
and laterally to the left midclavicular line. This is the PMI.
A nurse is obtaining a client's vital signs. The client has a new onset of a temperature of
39C (102F). Which of the following other vital signs should the nurse inspect?
- An elevated pulse rate
- A decreased blood pressure
- An elevated blood pressure
- A decreased pulse rate - answerAn elevated pulse rate.
A fever increases metabolic rate and peripheral vasodilation, resulting in an increased
pulse rate.
A nurse is collecting data about a clients respiratory condition. Which of the following
actions should the nurse take to determine the depth of the client's respiration?
- Observe the degree of chest-wall movement during inspiration and expiration.
- Count how many breathing cycles are observed per minute.
- Notice whether or not expiration takes longer than inspiration.
- Measure the precise amount of air the client takes in and breathes out. -
answerObserve the degree of chest-wall movement during inspiration and expiration.
The nurse can determine the depth of respiration subjectively by evaluating how much
chest-wall movement is observed. The movement is generated by the movements of
the diaphragm and intercostal muscles as the client breathes. With shallow respiration,
the nurse will observe very little movement. Deep respiration involves full expansion of
the lungs, which is usually quite visible.
A nurse is obtaining vital signs from a client. Which of the following findings is the
priority for the nurse to report to the provider?
- Oral temperature 37.8° C (100° F)
- Respirations 30/min
- BP 148/88 mm Hg
- Radial pulse rate 45 beats/30 seconds - answerRespirations 30/min
Respirations of 30/min is above the expected reference range of 12 to 20/min and
indicates the need for immediate attention. An adult client who has respirations of
30/min is experiencing shortness of breath, or dyspnea. Without intervention, this can
become a life-threatening situation.
A nurse is preparing to record the difference between a client's systolic and diastolic
blood pressure. Which of the following terms define this information when documenting?
- Auscultatory gap
, - Pulse pressure
- Orthostatic hypotension
- Pulse deficit - answerPulse pressure
The difference between the systolic and diastolic pressures is the pulse pressure. If the
client's blood pressure is 130/85 mm Hg, the pulse pressure is 45 mm Hg. Pulse
pressure can be a predictor of heart conditions, especially in older adults. For example,
an elevated pulse pressure usually reflects stiffness and reduced elasticity of the aorta,
most often due to hypertension or atherosclerosis.
A nurse is auscultating a client's apical pulse to loosens to the S1 and S2 hearts
sounds. S2 heart sounds are heard when which of the following occurs?
- When the atria contracts vigorously
- As the ventricular walls contract
- When the semilunar valves close
- As the mitral valve snaps open - answerWhen the semilunar valves close.
The second heart sound, S2, is generated by the closure of the aortic and pulmonic
valves, or semilunar valves, and signals the start of diastole. S2 is the "dub" heard in
the normal "lub-dub" sound.
A nurse is preparing to obtain a clients blood pressure. which of the following actions
should the nurse take to measure the blood pressure accurately?
- Obtain the reading in the early morning.
- Use a cuff of the appropriate size for the client.
- Assist the client to the bathroom to void.
- Apply the cuff loosely around the client's arm. - answerUse a cuff of the appropriate
size for the client.
Using the wrong cuff size for the client will result in an erroneous reading. A cuff that is
too small will result in a reading that is falsely high and using a cuff that is too big will
record a false low. One way to select a cuff is to make sure that the width of the cuff is
40% of the arm circumference where the cuff will be wrapped. The bladder, which is
inside the cuff, should surround 80% of the arm circumference.
A nurse is assessing a clients respiration. Which of the following actions should the
nurse take?
-Have the client lie flat in bed with their head on a pillow.
-Elevate the head of the client's bed 45° to 60°.
-Encourage the client to breathe shallowly.
-Ask the client to take several deep breaths prior to the assessment. - answerElevate
the head of the client's bed 45° to 60°.
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