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A 1-month-old infant has a head measurement of 34 cm and a chest circumference of 32 cm. Based on the interpretation of these findings, what action would the nurse take?
- A. Refer the infant to a physician for further evaluation.
- B. Consider these findings normal for a 1-month-old infant.
- C. Expect the chest circumference to be greater than the head circumference.
- D. Ask the parent to return in 2 weeks to re-evaluate the head and chest circumferences.
Correct Answer: B
Rationale: In infants, a normal head measurement is approximately 32 to 38 cm, and it is usually around 2 cm larger than the chest circumference. These measurements vary with age; between 6 months and 2 years, both measurements are approximately the same, and after age 2 years, the chest circumference becomes greater than the head circumference. Given that the 1-month-old infant's head measurement is within the typical range and slightly larger than the chest circumference, the nurse should consider these findings normal. There is no indication to refer the infant for further evaluation or to have the parent return for re-evaluation in 2 weeks, as these measurements fall within the expected parameters for a 1-month-old infant.
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Which of these guidelines would a healthcare professional follow when measuring a patient's weight?
- A. The patient is always weighed wearing only undergarments.
- B. The type of scale matters and should be consistent day to day.
- C. The patient should remove heavy outer clothing, shoes, and jackets before weighing.
- D. Attempts should be made to weigh the patient at approximately the same time of day if a sequence of weights is necessary.
Correct Answer: D
Rationale: When measuring a patient's weight, it is important to ensure accuracy and consistency. If a sequence of repeated weights is necessary, the healthcare professional should attempt to weigh the patient at the same time of day and with the same types of clothing worn each time. It is crucial to use a standardized balance or electronic standing scale for accurate weight measurement. Choice A is incorrect as patients should remove heavy outer clothing, shoes, and jackets before being weighed for accurate results. Choice B is incorrect because the type of scale used does matter and should be consistent for reliable weight tracking. Choice C is incorrect as patients should not leave on heavy outer clothing, shoes, or jackets as these items can add to the weight recorded inaccurately.
The nurse is assessing an 80-year-old male patient. Which assessment finding would be considered normal?
- A. Decrease in body weight from his younger years
- B. Decrease in deposits of fat in the cheeks and forearms
- C. Presence of kyphosis and flexion in bilateral knees and hips
- D. Change in overall body proportion, including a longer trunk and shorter extremities
Correct Answer: C
Rationale: In an 80-year-old male patient, the presence of kyphosis (rounded upper back) and flexion in bilateral knees and hips are considered normal age-related changes. These postural changes are commonly seen in older adults due to structural changes in the spine and joints. Option A is incorrect as aging individuals typically experience a decrease in body weight, not an increase. Option B is also incorrect as there is usually a decrease in subcutaneous fat from the face and periphery, rather than an increase in fat deposits in specific areas. Option D is incorrect because the change in overall body proportion with aging usually involves a shorter trunk and relatively longer extremities, not the other way around. This is because long bones do not shorten with age, leading to this characteristic change in body proportions.
During change-of-shift report, the nurse learns about the following four patients. Which patient requires assessment first?
- A. 40-year-old with chronic pancreatitis who has gnawing abdominal pain
- B. 58-year-old who has compensated cirrhosis and is complaining of anorexia
- C. 55-year-old with cirrhosis and ascites who has an oral temperature of 102°F (38.8°C)
- D. 36-year-old recovering from a laparoscopic cholecystectomy who has severe shoulder pain
Correct Answer: C
Rationale: When prioritizing patient assessments, the nurse should address the patient with cirrhosis and ascites who has an elevated oral temperature of 102°F (38.8°C) first. This presentation suggests a potential infection, which is critical to address promptly in a patient with liver disease. An infection in a patient with cirrhosis can quickly progress to severe complications. The other options, such as chronic pancreatitis with abdominal pain, compensated cirrhosis with anorexia, and post-laparoscopic cholecystectomy with shoulder pain, do not indicate an immediate life-threatening situation requiring urgent assessment compared to a possible infection in a patient with cirrhosis and ascites.
When taking blood pressures on a variety of people at a health fair, what should the nurse keep in mind?
- A. After menopause, blood pressure readings in women are usually higher than those taken in men.
- B. The blood pressure of an African-American adult is usually higher than that of a non-Hispanic White adult of the same age.
- C. Blood pressure measurements in people who are overweight are usually higher than those of people who are at a normal weight.
- D. A teenager's blood pressure reading may be lower than that of an adult.
Correct Answer: B
Rationale: When assessing blood pressures, it is important to consider that the blood pressure of African-American adults is typically higher than that of non-Hispanic White adults of the same age. This is significant as Black individuals in the United States have a higher prevalence of hypertension compared to other groups. Blood pressure readings in women are generally higher than in men after menopause. Additionally, blood pressure measurements in overweight individuals are typically higher than those in individuals of normal weight. While teenagers may have lower blood pressure readings than adults, it is crucial to recognize the trend of a gradual rise in blood pressure throughout childhood and into adulthood. Therefore, the correct choice is B. Choices A, C, and D are incorrect as they do not reflect the typical blood pressure differences observed in various populations.
Which technique is correct when assessing the radial pulse of a patient?
- A. Palpate for 1 minute if the rhythm is irregular.
- B. Palpate for 15 seconds and multiply by 4 if the rhythm is regular.
- C. Palpate for 2 full minutes to detect any variation in amplitude.
- D. Palpate for 10 seconds and multiply by 6 if the rhythm is regular and the patient has no history of cardiac abnormalities.
Correct Answer: A
Rationale: When assessing the radial pulse, if the rhythm is irregular, the pulse should be counted for a full minute to get an accurate representation of the pulse rate. In cases where the rhythm is regular, the recommended technique is to palpate for 15 seconds and then multiply by 4 to calculate the beats per minute. This method is more accurate and efficient for normal or rapid heart rates. Palpating for 30 seconds and multiplying by 2 is not as effective, as any error in counting results in a larger discrepancy in the calculated heart rate. Palpating for 2 full minutes is excessive and not necessary for routine pulse assessment. Palpating for 10 seconds and multiplying by 6 is not a standard technique and may lead to inaccuracies, especially in patients with cardiac abnormalities.