Chapter 09: General Survey and Measurement

Jarvis: Physical Examination and Health Assessment, 8th Edition

Multiple Choice

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

ANS: A

The general survey is a study of the whole person that includes observing the patient’s physical appearance, body structure, mobility, and behavior. Interpreting subjective data is not part of the general survey. Measuring the patient’s vital signs (temperature, pulse, respirations, and blood pressure) and observing specific body systems while performing a physical assessment are part of the physical examination, not the general survey.

DIF: Cognitive Level: Understanding (Comprehension)

MSC: Client Needs: Health Promotion and Maintenance a. The patient is always weighed wearing only his or her undergarments. b. The type of scale does not matter, 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 these are documented next to the weight. d. Attempts should be made to weigh the patient at approximately the same time of day, if a sequence of weights is necessary.

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

ANS: D

If a sequence of repeated weights is necessary, then the nurse should attempt to weigh the patient at approximately the same time of day and with the same types of clothing worn each time. A standardized balance or electronic standing scale should be used to measure weight. The patient should remove his or her shoes and heavy outer clothing. A patient does not need to always be weighed in their undergarments and should remove shoes and heavy outerwear. If a sequence of repeated weights is necessary, then the nurse should attempt to weigh the patient at approximately the same time of day and with the same types of clothing worn each time.

DIF: Cognitive Level: Understanding (Comprehension)

MSC: Client Needs: Health Promotion and Maintenance a. General health b. Genetic makeup c. Nutritional status d. Activity and exercise patterns

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

ANS: A

Physical growth is the best index of a child’s general health; recording the child’s height and weight helps determine normal growth patterns. A child’s physical growth is not the best indicator of genetic makeup, nutritional status, or activity and exercise patterns.

DIF: Cognitive Level: Remembering (Knowledge)

MSC: Client Needs: Health Promotion and Maintenance 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.

4. A 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?

ANS: B

The newborn’s head measures approximately 32 to 38 cm and is approximately 2 cm larger than the chest circumference. Between 6 months and 2 years, both measurements are approximately the same, and after age 2 years, the chest circumference is greater than the head circumference. There is no need to refer the infant for further evaluation or ask the parents to return in 2 weeks for re-evaluation because these findings are within normal.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Health Promotion and Maintenance a. Increase in body weight from his younger years b. Additional 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

5. The nurse is assessing an 80-year-old male patient. Which assessment findings would be considered normal?

ANS: C

Changes that occur in the aging person include postural changes of kyphosis and slight flexion in the knees and hips. Other changes that occur with aging include more prominent bony landmarks, decreased body weight (especially in men), a decrease in subcutaneous fat from the face and periphery, and additional fat deposited on the abdomen and hips. Postural changes of kyphosis and slight flexion in the knees and hips also occur. Changes that occur in the aging person include decreased body weight (especially in men), not increased body weight; a decrease in subcutaneous fat from the face and periphery, not an increase; and additional fat deposited on the abdomen and hips. Change in overall body proportion does occur but includes a shorter trunk with relatively longer extremities because long bones do not shorten with age rather than a longer trunk and shorter extremities.

DIF: Cognitive Level: Understanding (Comprehension)

MSC: Client Needs: Health Promotion and Maintenance a. Measuring the infant’s length by using a tape measure b. Weighing the infant by placing him or her on an electronic standing scale c. Measuring the chest circumference at the nipple line with a tape measure d. Measuring the head circumference by wrapping the tape measure over the nose and cheekbones

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

ANS: C

To measure the chest circumference, the tape is encircled around the chest at the nipple line. The length should be measured on a horizontal measuring board. Weight should be measured on a platform-type balance scale. Head circumference is measured with the tape around the head, aligned at the eyebrows, and at the prominent frontal and occipital bones—the widest span is correct. The height or length of an infant until 2-years-old should be measured on a horizontal measuring board, not using a tape measure. Weight of a 6-month-old should be measured on a platform-type balance scale. Head circumference is measured with the tape around the head, aligned at the eyebrows, and at the prominent frontal and occipital bones, not over the nose and cheekbones.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Health Promotion and Maintenance a. Chronic diseases such as hypertension cause weight loss. b. Weight loss is probably the result of unhealthy eating habits. c. Unexplained weight loss often accompanies short-term illnesses. d. Weight loss is probably the result of a mental health dysfunction.

7. A 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?

ANS: C

An unexplained weight loss may be a sign of a short-term illness or a chronic illness such as endocrine disease, malignancy, depression, anorexia nervosa, or bulimia. Hypertension, unhealthy eating, and mental health dysfunction are not common causes of unexplained weight loss.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Physiological Integrity: Physiological Adaptation a. Assume that the patient is eager and interested in participating in the interview. b. Evaluate the patient for abdominal pain, which may be exacerbated in the sitting position. c. Assume that the patient is having difficulty breathing and assist him to a supine position. d. Recognize that a tripod position is often used when a patient is having respiratory difficulties.

8. When 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?

ANS: D

Assuming a tripod position—leaning forward with arms braced on chair arms—occurs with chronic pulmonary disease. The other actions or assumptions are not correct.

DIF: Cognitive Level: Analyzing (Analysis)

MSC: Client Needs: Physiological Integrity: Basic Care and Comfort a. Sternal deformity and hyperextensible joints b. Growth retardation and a delayed onset of puberty c. Overgrowth of bone in the face, head, hands, and feet d. Increased height and weight and delayed sexual development

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

ANS: C

Excessive secretions of growth hormone in adulthood after normal completion of body growth causes an overgrowth of the bones in the face, head, hands, and feet but no change in height. Sternal deformity and hyperextensible joints are signs of Marfan syndrome. Growth retardation and a delayed onset of puberty are signs of hypopituitary dwarfism. Increased height and weight and delayed sexual development are characteristics of gigantism.

DIF: Cognitive Level: Understanding (Comprehension)

MSC: Client Needs: Safe and Effective Care Environment: Management of Care a. Body mass index (BMI) of 20 b. When standing, the patient’s base is narrow. c. The patient appears older than his stated age. d. Arm span (fingertip to fingertip) is greater than the height.

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

ANS: A

A body mass index (BMI) of 20 is normal. A normal BMI is 19-24. When standing, a patient’s base should be wide, and an older appearance than the stated age may indicate a history of a chronic illness or chronic alcoholism. When performing the general survey, the patient’s arm span (fingertip to fingertip) should equal the patient’s height. An arm span that is greater than the person’s height may indicate Marfan syndrome. When standing, a patient’s base should be wide, not narrow, and an older appearance than the stated age may indicate a history of a chronic illness or chronic alcoholism.

DIF: Cognitive Level: Understanding (Comprehension)

MSC: Client Needs: Health Promotion and Maintenance a. Body mass index b. Height and weight c. Head circumference d. Chest circumference

11. Which of these specific measurements is the best index of a child’s general health?

ANS: B

Physical growth, measured by height and weight, is the best index of a child’s general health.

DIF: Cognitive Level: Understanding (Comprehension)

MSC: Client Needs: Health Promotion and Maintenance a. Acromegaly b. Marfan syndrome c. Hypopituitary dwarfism d. Achondroplastic dwarfism

12. The 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?

ANS: C

Hypopituitary dwarfism is caused by a deficiency in growth hormone in childhood and results in a retardation of growth below the third percentile, delayed puberty, and other problems. The child’s appearance fits this description. Achondroplastic dwarfism is a genetic disorder resulting in characteristic deformities; Marfan syndrome is an inherited connective tissue disorder characterized by a tall, thin stature and other features. Acromegaly is the result of excessive secretion of growth hormone in adulthood which causes overgrowth of bone in the face, head, hands, and feet.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Physiological Integrity: Physiological Adaptation a. Gigantism b. Acromegaly c. Cushing syndrome d. Marfan syndrome

13. During an examination, the nurse notices that a female patient has a round “moon” face, central trunk obesity, and a cervical hump. Her skin is fragile with bruises. The nurse determines that the patient likely has which condition?

ANS: C

Cushing syndrome is characterized by weight gain and edema with central trunk and cervical obesity (buffalo hump) and round plethoric face (moon face). Excessive catabolism causes muscle wasting; weakness; thin arms and legs; reduced height; and thin, fragile skin with purple abdominal striae, bruising, and acne. Gigantism is characterized by increased height and weight and delayed sexual development. Acromegaly is the result of excessive secretion of growth hormone in adulthood which causes overgrowth of bone in the face, head, hands, and feet. Marfan syndrome is an inherited connective tissue disorder characterized by a tall, thin stature and other features. The signs in this question indicate Cushing syndrome.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Physiological Integrity: Physiological Adaptation