A 1-month-old infant has a head measurement of 34 cm and has a chest circumference of 32 cm.

NURS330 Individual Assessment

Chapter 9 Quiz

Question 1A 1-month-old infant has a head measurement of 34 cm and has a chest circumference of 32 cm. Based on the interpretation of these findings, what action should the nurse take?

 

  Refer the infant to a physician for further evaluation.

 

  Consider these findings normal for a 1-month-old infant.

 

  Expect the chest circumference to be greater than the head circumference.

 

  Ask the parent to return in 2 weeks to re-evaluate the head and chest circumferences.

 

Question 2Which of these guidelines should a nurse follow when measuring a patient’s weight?

 

  The patient is always weighed wearing only his or her undergarments.

 

  The type of scale does not matter, as long as the weights are similar from day to day.

 

  The patient may leave on his or her jacket and shoes as long as these are documented next to the weight.

 

 

 

  Attempts should be made to weigh the patient at approximately the same time of day, if a sequence of weights is necessary.

 

Question 3A 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. Which is an appropriate rationale for this patient’s weight loss?

 

  Chronic diseases such as hypertension cause weight loss.

 

  Weight loss is probably the result of unhealthy eating habits.

 

  Unexplained weight loss often accompanies short-term illnesses.

 

  Weight loss is probably the result of a mental health dysfunction.

 

Question 4In a patient with acromegaly, which assessment finding will the nurse expect to find?

 

  Sternal deformity and hyperextensible joints

 

  Growth retardation and a delayed onset of puberty

 

  Overgrowth of bone in the face, head, hands, and feet

 

  Increased height and weight and delayed sexual development

 

 Question 5When performing an examination, the nurse should consider a child’s physical growth to be the best indicator of which aspect of health?

 

  General health

 

  Genetic makeup

 

  Nutritional status

 

  Activity and exercise patterns

 

Question 6When 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. How should the nurse interpret these findings?

 

  Assume that the patient is eager and interested in participating in the interview.

 

  Evaluate the patient for abdominal pain, which may be exacerbated in the sitting position.

 

  Assume that the patient is having difficulty breathing and assist him to a supine position.

 

  Recognize that a tripod position is often used when a patient is having respiratory difficulties.

 

Question 7The nurse is preparing to measure the length, weight, chest, and head circumference of a 6-month-old infant. Which measurement technique is correct?

 

  Measuring the infant’s length by using a tape measure

 

  Weighing the infant by placing him or her on an electronic standing scale

 

  Measuring the chest circumference at the nipple line with a tape measure

 

  Measuring the head circumference by wrapping the tape measure over the nose and cheekbones

 

Question 8The nurse is performing a general survey of a patient. Which finding is considered normal?

 

  Body mass index (BMI) of 20

 

  When standing, the patient’s base is narrow.

 

  The patient appears older than his stated age.

 

  Arm span (fingertip to fingertip) is greater than the height.

 

Question 9The nurse is performing a general survey. Which action is a component of the general survey?

 

  Observing the patient’s body stature and nutritional status

 

  Interpreting the subjective information the patient has reported

 

  Measuring the patient’s temperature, pulse, respirations, and blood pressure

 

  Observing specific body systems while performing the physical assessment

 

Question 10The 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 likely have?

 

  Acromegaly

 

  Marfan syndrome

 

  Hypopituitary dwarfism

  Achondroplastic dwarfism

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