Professional Documents
Culture Documents
Health Assessment
Health Assessment
Maria presents with c/o abdominal pain, nausea and vomiting. The physician requests that you obtain a
rectal temperature. Her temperature is 102.7. How do you document her temperature? T=102.7 (R)
2.
When you take Maria's blood pressue, her systolic pressure is 90 and her diastolic is 50. How do you chart her blood
pressure? BP=90/50
3.
Maria's respirations are 24. This is a normal range for respirations.
A. false
True
B.
o
False
4.
Correctly document Maria's respirations. The previous question stated that they are 24. R 24
5.
Maria has now begun to have diarrhea. It has been 45 minutes since she was given a Tylenol suppository for her
fever. The doctor asks you to evaluate her response to the Tylenol by rechecking her temperature. What method will
you use?
A.
Oral
B.
o
Axillary
C.
o
Rectal
D.
o
Aural
6.
The temperature recheck is 101.1. How should you document the temperature? 101.1 T
7.
Maria's pulse rate is 100. This is a normal pulse rate.
A.
True
B.
False
8.
How do you correctly document Maria's pulse of 100? P 100
9.
Martin is 6 months old. You have been tasked to obtain his height and weight. He will not remain still on the scale
and you are afraid that he will roll off. You improvise......you weigh his Mom and she is 165.3 pounds. You weigh
Mom again while she is holding Martin. Together they weigh 177.8 pounds. How do you document Martin's weight?
Wt 12.5 lbs
10.
To get Martin's height, you lay him on the exam table and mark the paper at the top of his head and his outstretched heel. You measure the distance between the marks and get 28 inches. Document his height. Ht 28
Ht 2ft 4 in
The blood pressure cuff that is selected to use on the patient may provide an inaccurate result if the incorrect size is
chosen.
A.
True
B.
o
False
2.
______________ is the component of the nursing process in which the nurse makes the decision that the current
issue is resolved or requires further nursing interventions.
A.
Assessment
B.
o
Diagnosis
C.
Outcome /planning
D.
o
Interventions
o
E.
Evaluation
3.
General appearance includes which of the following components as part of the assessment? (Mark all that apply)
A.
Grooming
B.
o
Odor
C.
o
Skin color
D.
o
Conversive
E.
o
Nail polish
4.
Pain is what the patient says it is.
A.
True
B.
o
False
5.
The ___________ temperature is measured in the armpit.
6.
What scale would you use to assess pain in an alert and oriented adult patient?
A.
FLACCS scale
B.
o
FACES scale
C.
o
CPOT
7.
A care plan informs the physician what he needs to address with the patient an their family.
A.
True
B.
o
False
8.
The five vital signs are temperature, blood pressure, pulse, __________ and pain.
9.
An assessment must be completed on the patient prior to determining a nursing diagnosis.
A.
True
B.
o
False
10.
If the patient is clean and well dressed they are probably healthy
A.
True
B.
o
False
o
98.6
C.
o
99.6
2.
Normal Pulse ___
A.
50-60
B.
o
60-100
C.
o
100-120
3.
Normal Respiration ___
A.
12-16
B.
o
12-20
C.
o
12-24
4.
o
90-110
C.
o
100-120
5.
o
60-80
C.
o
80-89
6.
The process of temperature regulation in body is known as ___
A.
o
Thermostat
B.
o
Thermoregulation
C.
o
Hyperthymus
7.
Loss of heat through electromagnetic wave ____
A.
Radiation
B.
o
Convection
C.
o
Evaporation
8.
Transfer of heat through circulation of heat and water ___
A.
Evaporation
B.
o
Convection
C.
o
Radiation
9.
___ Occurs when water is converted into vapour and lost from the skin
A.
Radiation
B.
o
Evaporation
C.
o
Conduction
10.
___ is the process by which heat is transferred from warm to cool surface
A.
Radiation
B.
o
Conduction
C.
o
Convection
11.
Pyrexia means ___
A.
Coldness
B.
o
Shivering
C.
12.
Fever occurs in ___ phases
A.
1
B.
o
3
C.
o
5
13.
Hypovolemia is ___
A.
Fever
B.
o
Anemia
o
C.
Dehydration
14.
Fever producing substance are called ___
A.
Pathogens
B.
o
Pythons
C.
o
Pyrogens
15.
Hypothermia exists when temperature falls below ___ degree
A.
96.8 F
B.
o
98.6 F
C.
o
95.6 F
16.
Sever Hypothermia occurs when Temp drops below ___ degree
A.
80.4 F
B.
o
82.4 F
C.
o
84.2 F
17.
Contraction of heart can be called ___
A.
Blood Pressure
B.
o
Diastole
C.
o
Systole
18.
Resting Phase of heart is known as ___
A.
Diastole
B.
o
Systole
C.
o
Cardiac output
19.
Total quantity of blood pumped per minute ___
A.
Cardiac output
B.
o
Stroke Volume
C.
o
Heart Rate
20.
___ is the quantity of blood pushed out by each contraction.
A.
Cardiac output
B.
o
Systole
C.
o
Stroke Volume
21.
Feeling the pulse is called ___
A.
Auscultation
B.
Palpation
C.
o
Pulse Rate
22.
Listening the pulse with a stethoscope is ___
A.
Palpation
B.
o
Auscultation
C.
o
Evaluation
23.
___ is the exchange of gases between capillaries and body tissue cells
A.
Internal Respiration
B.
External respiration
C.
Pulmonary Ventilation
24.
Mechanical aspect of respiration in respiratory system ___
A.
Internal Respiration
B.
Pulmonary Ventilation
C.
External respiration
25.
Air taken in on inspiration 300-500ml is ___
A.
Breathing
B.
o
Ventilation
C.
o
Tidal Volume
26.
Peripheral chemo receptors in the ___ and ___ bodies simulate respiration.
A.
Aarotid, Cortic
B.
Carodine, Aerodine
C.
o
Carotid, Aortic
27.
Cessation of breath is called ___
A.
Apnea
B.
o
Eupnea
C.
o
Bradypnea
_____ is reflected in the vital signs by indicating the status of the body's function, which is regulated through
homeostatis mechanisms and falling within certain normal ranges.
A.
Lifestyle
B.
o
Vital signs
C.
o
Homeostasis
D.
o
Health status
E.
2.
How often are vital signs assessed in patients who are taking medications that affect cardiovascular or respiratory
function or who have had surgery? Every:
3.
True or false:A nurse can delegate to other healthcare personnel to do vital sign assessment of patients.
A.
True
B.
o
False
4.
Body temperature indicates the difference between the ____ of heat and the ____ of heat. (separate answers with a
space)
5.
Core body temperature is normally maintained within the rage of ____ degrees F to _____ degrees F. (separate
answers with a space)
6.
Core body temperature is highest at:
A.
Early morning
B.
o
Noon
C.
o
Late afternoon
D.
o
Evening
E.
o
Night
Discuss
7.
o
Higher than
C.
o
Equal to
D.
8.
Core temperatures are not measured at:
A.
Tympanic site
B.
o
Rectal site
C.
o
Bladder
D.
o
Sublingual site
E.
9.
Core body temperature is normally maintained within a rage of ____ degrees C and ____ degrees C. (separate
answers with a space)
10.
A newborn's temperature should be
A.
37 degrees Celcius (oral)
B.
37 degrees Celcium (axillary)
C.
11.
A normal temperature for a child between 1-3 years of age is:
A.
37.7 degrees Celcius (axillary)
B.
12.
The normal temperature for an adult is:
A.
37 degrees Celcius (axillary)
B.
13.
The average temperature of an adult older than 70 years of age is _____ degrees celcius orally.
Discuss
14.
The average pulse for a teen is
A.
80-180 bpm
B.
o
75-110 bpm
C.
o
80-140 bpm
D.
o
60-120 bpm
E.
o
60-100 bpm
15.
The primary source of heat in the body is _____
16.
____ is produced as a byproduct of metabolic activities that generate energy for cellular functions.
Discuss
17.
When additional heat is required to maintain balance, epinephrine and norepinephrine (sympathetic
neurotransmitters) are released and alter metabolism so that energy production ____ and heat production ____.
(separate answers with a space)
18.
Which hormone increases metabolism and heat production, but over a much longer time period than epinephrine and
norepinephrine.
19.
_____ is a response that increases the production of heat; it is initiated by the hypothalamus and results in muscle
tremours.
20.
______ occurs with shivering, causing "goose bumps" and reducing the size of the surface to minimize heat loss.
Discuss
21.
Shivering and piloerection are forms of:
A.
Heat loss
B.
o
Heat production
C.
Environmental temperature
D.
o
Fever
E.
22.
Connections in the skin that remain open to allow heat to dissipate to the skin or close to retain heat in the body are
called
23.
Which of the following controls the opening and closing of the arteriovenous shunts in response to changes in core
body temperature and in environmental temperature.
A.
Autonomic nervous system
B.
o
All of the above
E.
24.
True or False:Heat production also occurs through warming and humidigying of inspired air and elimination of urine
and feces.
A.
True
B.
o
False
25.
Which group's body temperature changes more rapidly in response to both heat and cold air temperatures?
A.
Infants and children
B.
o
Older adults
C.
o
Women
D.
o
Men
E.
26.
Which group lose some thermoregulatory control and are at risk for harm from extremes of temperature?
A.
Infants and children
B.
o
Older adults
C.
o
Women
D.
o
Men
E.
27.
Which group tends to have more fluctuations in body temperature, probably due to the result of changes in
hormones/ The increase in progesterone secretion increases body temperature as much as 0.5F to 1.0F.
Discuss
28.
When one is exposed to extreme cold without adequate protective clothing, heat loss may be increased to the point
of _____, which can lead to serious illness or death.
29.
When one is exposed to extreme heat for long periods of time _____ may result, which can lead to serious illness or
death.
30.
When the body gives off waves of heat from uncovered surfaces, it is called
31.
____ occurs when oscillating fan blows currents of cool air across the surfaces of a warm body.
32.
The conversion of a liquid to vapour is called
33.
The transfer of heat to another object during direct contact is called _____
34.
An example of ____ is when the body transfers heat to an ice pack, causing the ice to melt.
35.
When a person has a normal body temperature it is called
A.
Afebrile
B.
o
Febrile
C.
o
Pyrexia
D.
o
Hyperpyrexia
E.
o
Hypothermia
36.
Two terms synonymous to "fever" are:(separate answers with a space)
Discuss
37.
A mild elevation in temperature might indicate a serious infection in infants younger than _____ of age who do not
have a well-developed temperture-control mechanism.
A.
2 months
B.
3 months
C.
o
6 months
D.
o
1 year
E.
o
2 years
38.
The difference between hyperthermia and pyrexia is: Fever occurs when the body temperature is raised without the
consent of the heat control centers. A hyperthermia occurs when the body sets the core temperatures to a higher
temperature, through the action of the pre-optic region of the hypothalamus.
A.
True
B.
o
False
39.
A temperature less than 95 degrees F is termed
40.
A temperature between 100.5 and 105 degrees F is termed
41.
A temperature above 105.8 is termed
42.
In older adults, fever may be an [early or later] sign of illness.
Discuss
43.
When the set point is increased, as in fever, the hypothalamus inatiates
A.
Sweating
B.
o
Shivering
C.
o
Vasoconstriction
o
D.
A and C
E.
o
B and C
Discuss
44.
True or False:Most fevers are not self-limiting.
A.
True
B.
o
False
45.
Hyperthermia differs from fever in that the hypothalamic set point is changed, and in situations of extreme heat
exposure the mechanisms that control the body temperature are ineffective.
A.
True
B.
o
False
46.
If the cause of any type of fever is difficult to determine, it is often diagnosed as
47.
Drugs, such as aspirin or acetaminophen, are believed to lower the elevated set point regulated by the hypothalamus
are called _____. They do not affect body temperature when it is within normal range.
48.
Apart from administering antipyretic drugs, name one possible nursing intervention used to lower body temperature.
Discuss
49.
Which type of fever is defined as: the body temperature alternates regularly between a period of fever and a period of
normal or subnormal temperature.
50.
Which type of fever is defined as: The body temperature fluctuates several degrees more than 2 degrees C (3.6 F)
above normal but does not reach normal betwenn fluctuations.
51.
Which type of fever is defined as: the body temperature remains consistently elevated and fluctuates less than 2
degrees C (3.6 F)
Discuss
52.
What terms used to describe fever is defined as: The fever returns to normal suddenly
Discuss
53.
What term that describes fever is defined as: The fever retruns to normal gradually.
54.
Non-mercury glass thermometers may be either spirit-filled (using a petroleum-based liquid) or alcohol-based; the
bulb contains a liquid that _____ with heat and rises within the stem.
55.
Some disposable single-use thermometers, that are commonly applied to abdomen or forehead, often of young
children and toddlers, have a temperature-senstive patch or tape what changes ______
Discuss
56.
This type of thermometer is swiped across the skin over the respective artery, taking 1000 readings per second and
selecting the most accurate.
A.
Carotid artery thermometer
B.
57.
Many enironmental and physiologic processes occur in repeated cycles of time, such as _____ _______ which is 24hour intervals.
58.
A throbbing sensation that can be palpated over a peripheral artery or auscultated over the apex of the heart is called
a
59.
The pulse is regulated by the autonomic nervous system through the cardiac sinoatrial (SA) node. ______ stimulation
of the SA node via the vagus nerve decreases the heart rate, and _______ stimulation of the SA node increases the
heart rate and force of contraction.
A.
Sympathetic; somatic
B.
Sympathetic; parasympathetic
C.
Parasympathetic; sympathetic
D.
Parasympathetic; somatic
E.
60.
Parasympathetic stimulation of the SA node via the ______ nerve decreases the heart rate.
61.
_______ mechanisms attempt to maintain a sufficient supply of blood to the cells at all times.
62.
Normal pulse rate for adolescences and adults rangers from _____ to _____ beats per minute.
A.
60 - 90 bpm
B.
o
50 - 100 bpm
C.
o
60 - 120 bpm
D.
o
50 - 110 bpm
E.
63.
What is the term used to describe decreased cardiac filling time, which, in turn, decreases stroke volume and cardiac
output, due to rapid rate.
Discuss
64.
Tachycardia is a pulse rate between ____ and ___ bpm. (separate answers with a space)
65.
Which of the following does not contribute to tachycardia.
A.
o
Medications
B.
Elevated temperature
C.
o
Anemia
E.
66.
What is the term used to describe a pulse rate below 60 bpm
67.
WHich of the following doesn't contribute to bradycardia
A.
Obesity
B.
o
Medications
C.
o
Being alseep
D.
o
Being a man
E.
68.
Bradycardia is a pulse rate below ___ bpm
69.
Sinus bradycardia results from the ____ ____ creating a slower-than-normal impulse rate.
70.
Sinus bradycardia is not caused by which of the following:
A.
o
During sleep
C.
o
Severe pain
D.
o
Hyperthermia
E.
o
Vagal stimulation
71.
Emergency treatment for severe bradycardia is the administration of _____ intravenously to block vagal stimulation
and to restore normal heart rate.
Discuss
72.
The pulse amplitude describes the quality of the pulse in terms of its fullness and reflects the strength of _____
contraction
A.
Right ventricle
B.
o
Left ventricle
C.
o
Aorta
D.
o
Right atrium
E.
o
Left atrium
Discuss
73.
An irregular pattern of heartbeats is called a
Vital signs includes, blood pressure, Pulse, Temp. Resp. rate & Oxygen saturation.
A.
True
B.
o
False
2.
Where is temperature is regulated?
A.
Hypothalamus
B.
o
Skin
C.
o
Heat & Cold
D.
3.
What is the normal range of temperature?
A.
36.6-37.5 c
B.
o
34-36 c
C.
o
34.6-36 c
D.
o
35.6-38 c
4.
What is the normal pulse rate?
A.
12-20
B.
o
15-20
C.
o
60-100
D.
o
50-80
5.
A weak pulse is rated as
A.
0
B.
o
1+
C.
o
2+
D.
o
3+
E.
o
4+
6.
A patient have a pulse rate of 102, resp. rate of 25, a B/P of 139/90 and a temp. of 103 F. As a nurse which will you
assess first?
A.
B/P of 139/90
B.
o
Pulse of 102
C.
o
Resp. rate of 25
D.
o
Temp. of 103 F
7.
What is the maximum of oxygen can you give a patient with COPD?
A.
2 L/min
B.
o
10 L/min
C.
o
4 L/min
D.
o
6 L/min
8.
Blood pressure is the force against the aterial wall
A.
True
B.
o
False
9.
A person that is dehydrated will experience a low B/P
A.
True
B.
o
False
10.
What factor does not influence Resp. rate?
A.
Age
B.
o
Gender
C.
o
Smoking
D.
o
Medication
E.
o
Pain
11.
COPD regulation is by hypoxemia via chemoreceptors in the brain
A.
True
B.
o
False
12.
Eupnea is another word for difficulty breathing
A.
True
B.
o
False
13.
Pulse deficit is the difference between the apical and radial rate
A.
True
B.
o
False
14.
A patient has a radial pulse of 65 & a apical rate of 66, What is the pulse deficit?
A.
0
B.
o
1
C.
o
1+
D.
o
131
15.
A patient with a Temp. of 104 F and a damage hypothalamus, will you give antipyretic to lower the temperature?
A.
True
B.
o
False
o
Fainting
D.
2.
A change in one or more of the vital signs could indicate a change in the overall health of a patient
A.
True
B.
o
False
3.
Check which vital signs are abnormal in a healthy 32 year old male: T: 103 F, PR: 90, RR: 44, B.P: 112/76 mmHG
A.
Temperature
B.
o
Pulse rate
C.
o
Respiratory rate
D.
o
Blood pressure
4.
A patient with vertigo would have dizziness and feel the sensation of the room spinning
A.
True
B.
False
5.
All of the following are characteristics the medical assistant should note while measuring a pulse
A.
Rate
B.
o
Rhythm
C.
o
Volume
D.
o
All of the above
6.
Anthropometric measurements include the following EXCEPT
A.
Weight
B.
o
Height
C.
o
Body mass index
D.
7.
The blood pressure cuff has to be deflated between readings
A.
True
B.
o
False
8.
Body temperature is regulated by the hypothalamus
A.
True
B.
o
False
9.
Convert the following weight 145 lb= ___________kg use this conversion tools *make sure you put the unit of
measurement after the conversion... for example..________lb or kg 1kg= 2.2lb 1lb= 0.45 kg
10.
If a bedridden patient has chills and shivering you would expect the body temp to be decreased
A.
True
B.
o
False
11.
The systolic pressure may be checked by the radial pulse method if the medical assistant is unable to auscultate the
patient's blood pressure
A.
True
B.
o
False
12.
Which of the following can affect a patient's blood pressure reading
A.
Caffeine
B.
o
Exercise
C.
o
All of the above
13.
Pre-hypertension can be considered a normal physiological process that doesn't need any further investigation
A.
True
B.
False
14.
Hyperlipidemia is an over production of which substance in one's blood?
A.
Carbohydrates
B.
o
Protein
C.
o
Fat
D.
15.
If a pulse is consistently high above 100 bpm, then this pulse is said to be
A.
Bradycardic
B.
o
Tachypneic
C.
o
Tachycardic
D.
16.
120/80= the second number which stands for the second tapping sound is called
A.
Systolic
B.
o
Diastolic
C.
o
Both
o
D.
None of the above
17.
Which is NOT a cardinal vital sign
A.
Temp
B.
o
Pulse
C.
o
Respiration
D.
18.
Diastolic pressure is explained by
A.
Contraction
B.
o
Relaxation
C.
o
Both
D.
19.
How long should the pulse be counted for the most accurate results?
A.
15 seconds multiplied by 4
B.
30 seconds multiplied by 2
C.
o
60 seconds
D.
o
45 seconds
20.
Atherosclerotic Plaques can lead to hypertension
A.
True
B.
o
False
21.
The following explains systolic pressure
A.
Relaxation
B.
o
Contraction
C.
o
Both
D.
o
o
22.
Match the following pulse sites
A. apical
A.
Select a Match
B. brachial
B.
o
o
Select a Match
23.
The optimal blood pressure according to the JNC guidelines is
A.
At 120/80
B.
o
More than 120/80
C.
o
Less than 120/80
o
D.
None of the above
24.
A 27 year old male comes in for an annual physical. Jasmine the medical assistant student comes in reads his blood
pressure and reads at 140/95. One can say this patient is
A.
Hypertensive
B.
o
Normal
D.
25.
The following blood pressure reading : 90/60, most likely resembles which type of blood pressure?
A.
Hypertensive
B.
o
Normotensive
C.
o
Hypotensive
D.
26.
A 33 year old female tri-athlete is very well conditioned. We expect her pulse rate to be;
A.
High
B.
o
Very high
C.
o
Low
o
D.
None of the above
27.
If one palpates a pulse on the wrist underneath the thumb, this pulse is called the
A.
Ulnar
B.
o
Brachial
C.
o
Apical
D.
28.
120/80= This first number which corresponds to the first tapping sound is called the
A.
Diastolic
B.
o
Systolic
C.
o
All of the above
D.
29.
A 23 year old female has a temperature reading of 102 F, this is reading is said to be
A.
Afebrile
B.
o
Febrile
C.
o
Normal
o
D.
None of the above
30.
A 75 year old female had diffuclty recovering from the flu and developed Pneumonia as a consequence, the doctor
listened to her breath sounds and found the following sound
A.
Apnea
B.
o
Arrhythmia
C.
o
Rales
D.
31.
A patient in good health comes to the clinic for a physical. Her temperature is elevated and reads at 101 C. What
could be the reason for the sudden rise in temp?
A.
Cold weather
B.
o
Eating ice cream
D.
32.
Malnourishment could be a cause of delayed growth in a child
A.
True
B.
o
False
33.
A good pulse site is the palpation of the ulnar artery
A.
True
B.
False
34.
Palpating the dorsalis pedis artery pulse is a great method in evaluating blood flow to the brain
A.
True
B.
o
False
35.
A diet low in sodium is a great way to reduce blood pressure
A.
True
B.
o
False
36.
Which would cause hyperlipidemia?
A.
Diet high in protein
B.
o
Diet high in carbs
C.
o
Diet high in fat
D.
o
o
37.
Match the palpation sites
A. popliteal
A.
Select a Match
B. dorsalis pedis
B.
o
o
Select a Match
38.
Match the vital signs with the appropriate terms
A. Temp: 104 F
A.
Select a Match
B. Temp: 97 F
B.
o
o
Select a Match
o
o
39.
Match the vital signs with the appropriate terms
A. BP: 120/80
A.
Select a Match
B. BP: 119/79
B.
o
o
Select a Match
o
o
40.
Match the vital signs with the appropriate terms RR= respiratory rate
A. RR: 44
A.
Select a Match
o
o
B. RR: 13
B.
Select a Match