NR-302 Health Assessment I - Set 2 - Part 1

Correct Answer: Pull the pinna down and back

Under three years of age the canal points upward, so pulling the pinna down and back straightens it and brings the drum into view. Above that age the pinna is pulled up and back. Option a is incorrect because that direction suits an adult or a child older than three, whose canal angles differently. Used on a toddler it leaves the canal kinked and the membrane hidden. Option b is incorrect because resting the ulnar side of the hand against the head is the key safety step with a moving child. Without it a sudden turn can drive the speculum into the canal. Option d is incorrect because the widest speculum that fits comfortably gives the broadest view and a better seal. Choosing a narrow tip shrinks the field and tempts the examiner to insert it too far.

Correct Answer: The cuff was too narrow for this arm

An adult cuff on an oversized arm sits below the width the limb requires, so the nurse must inflate well past the true arterial pressure to occlude the vessel and the recorded value climbs. Option b is incorrect because an oversized bladder pulls readings down, not up. Had that been the mistake here, the number would have understated the client's pressure and hidden any real elevation. Option c is incorrect because a diagnosis cannot rest on one reading taken with a cuff that does not fit. Undercuffing is common enough to relabel a normotensive client, and the history argues against sudden disease. Option d is incorrect because tucking the diaphragm beneath the cuff edge adds rubbing artifact and muffles the Korotkoff sounds. That fault obscures what the nurse hears rather than inflating both numbers together.

Correct Answer: The diaphragm placed directly on the skin

Bowel sounds are high pitched and gurgling, so the diaphragm is the correct endpiece. It must sit directly on bare skin, since fabric rubbing the surface creates artifact and muffles the sounds being counted. Option a is incorrect because the cupped endpiece is reserved for low frequency sounds such as vascular bruits and the third and fourth heart sounds. Gurgling from the intestine sits far above that range. Option b is incorrect because listening through cloth introduces a crackling rub that mimics adventitious sound and hides quiet intestinal activity. The gown is opened and the endpiece meets the abdominal wall itself. Option d is incorrect because bearing down on the cup stretches the skin taut, converting it into a diaphragm and defeating the reason for choosing it. Firm pressure on the abdomen also stimulates peristalsis.

Correct Answer: Turn on strong lighting and inspect again

Early cyanosis and pallor are routinely missed in a darkened room, so adequate light must come before any conclusion about color. Inspection is repeated under strong even lighting, with the mucous membranes and nail beds examined. Option b is incorrect because percussion maps tissue density and would not settle a question about color that poor lighting created. Skipping ahead to a later technique leaves the flawed observation uncorrected. Option c is incorrect because feeling for air under the skin answers a different clinical question entirely. Hands cannot recover the visual data that dim light hid, and touching moves past the failed step. Option d is incorrect because charting a finding gathered under inadequate conditions passes an unreliable observation to the next clinician. A falling saturation alongside an unchanged color entry is a contradiction demanding another look.

Correct Answer: Touch alters the resting posture inspection would capture

Inspection gathers information that is free and unrepeatable once the client has been disturbed. Touching a painful joint first provokes guarding and tension, so the resting position and spontaneous movement can no longer be seen. Option a is incorrect because ranking one technique above another misses the point of the sequence. Each technique yields different data, and looking supplies the map that tells the examiner where hands should go. Option b is incorrect because gloves are worn when contact with body fluids or non-intact skin is possible, not as a rule for looking. Exposure is limited to the region under examination. Option d is incorrect because percussion sets tissue vibrating through a striking blow and would hurt an inflamed joint just as much. Swapping techniques does nothing about the order error the student made.

Correct Answer: The normal diurnal swing across the day

Body temperature follows a circadian rhythm, running lowest between roughly four and six in the morning and peaking in the late afternoon or early evening. A swing of about one degree is expected. Option a is incorrect because fever is defined at 100.4 degrees Fahrenheit or higher, and neither reading reached that threshold. Nothing here describes chills, flushing, or the diaphoresis that follows a resolving fever. Option b is incorrect because blaming the device ignores a predictable physiologic pattern that every client shows. Suspecting equipment failure is reasonable when a value clashes with the clinical picture, and both readings here were normal. Option c is incorrect because no medication is mentioned in the scenario, and antipyretics lower rather than raise temperature. Attributing an ordinary daily rise to a drug effect invents a cause the data do not support.

Correct Answer: The client reports sharp pain on impact

Blunt percussion over the costovertebral angle normally produces a thud the client feels without pain. Pain on impact suggests inflammation of the kidney, and with flank pain and fever it points toward pyelonephritis. Option b is incorrect because a painless thud is the expected response and would reassure rather than alarm. Blunt percussion here tests for tenderness, so an unremarkable sensation counts as a normal result. Option c is incorrect because this maneuver is not judged by the sound at all. Resonance describes air filled lung and would say nothing about whether the kidney beneath is inflamed. Option d is incorrect because a drum like note comes from air within the bowel, heard on abdominal percussion rather than over the posterior flank. Fist percussion looks for a pain response instead.

Correct Answer: Obtain a correctly sized cuff and remeasure

A bladder too wide for a slender arm occludes the artery early and reports a pressure below the truth, so the nurse finds a cuff matched to the arm and repeats the measurement. Option a is incorrect because withholding medication on the strength of a suspect number can leave real hypertension untreated. The nurse verifies the measurement first, and dose decisions belong to the prescriber anyway. Option b is incorrect because calling the provider about an unverified value wastes the call and may trigger orders built on a false premise. Verification precedes escalation whenever a reading looks out of character. Option d is incorrect because a standing check answers a different question, whether posture drops the pressure further. It repeats the same oversized cuff error while adding a fall risk for a frail client.

Correct Answer: Systolic falsely low and diastolic falsely high

Dropping the pressure too fast skips past the first Korotkoff tap and reaches silence before the true endpoint, so the systolic is recorded under its real value and the diastolic above it. Option a is incorrect because the pattern runs the other way around. Rapid release means the gauge has already fallen past the pressure at which the first sound truly appeared, pulling the systolic down. Option b is incorrect because a uniform rise in both numbers describes a different set of faults, such as a narrow cuff, a crossed leg, or an arm hanging below the heart. Option c is incorrect because only the systolic sinks with fast deflation. The diastolic moves upward instead, since the needle passes the point of true silence before the ear registers that the sounds stopped.

Correct Answer: About forty percent of the arm circumference

Bladder width is matched to roughly two fifths of the arm circumference so the cuff transmits pressure evenly to the brachial artery without needing extra inflation to reach it. Option b is incorrect because eighty percent is the figure for bladder length, the dimension that wraps around the limb. Applying it to width would give a cuff far too broad for the arm. Option c is incorrect because a bladder that spans only a fifth of the circumference behaves like an undersized cuff. It compresses through too much tissue and pushes the recorded numbers upward. Option d is incorrect because matching width to the full circumference produces an enormously oversized bladder. Such a cuff yields to a low inflation pressure, and the numbers recorded land under the client's true arterial pressure.

Correct Answer: Inspect the conjunctivae, oral mucosa and nail beds

Melanin hides the dusky cast of cyanosis, and only severe cyanosis becomes apparent on the skin surface. The least pigmented windows, the conjunctivae, oral mucosa and nail beds, show desaturation far sooner. Option a is incorrect because documenting adequate perfusion records a conclusion the nurse has not yet tested. Skin surface color is the least sensitive window in dark skin, and a hypoxemic client would be charted as stable. Option b is incorrect because warming addresses peripheral vasoconstriction from cold, which is a different cause of dusky nail beds. Delaying the examination to warm a breathless surgical client wastes minutes that central assessment needs. Option d is incorrect because pulse oximetry can overestimate true saturation in clients with darker pigmentation, producing occult hypoxemia. A single reassuring number cannot substitute for looking at the least pigmented tissues and the work of breathing.

Correct Answer: Expose and re-cover one region at a time

Draping is a clinical skill. The nurse opens the gown over the area being examined, examines it, and closes it again before moving on, which preserves warmth, dignity and the client's willingness to cooperate. Option a is incorrect because prolonged uncovering chills a partly undressed client and provokes shivering, which raises muscle tension and adds noise during auscultation. It also ignores what the client has just said. Option b is incorrect because hurrying degrades the examination itself, and inspection in particular suffers when the examiner rushes. An open gown offers no protection to a client who has voiced concern about exposure. Option c is incorrect because four raised rails prevent the client from leaving the bed and count as a restraint requiring a provider order. Modesty is not addressed by confining someone either.

Correct Answer: Document the pattern and discuss genetic referral

Early onset disease, several affected relatives and a pattern running through generations are the red flags for an inherited condition. The nurse records the detail and raises genetic counseling with the provider. Option b is incorrect because three first and second degree relatives with early disease raise risk substantially. False reassurance here may cost the client earlier screening at the age when it would matter. Option c is incorrect because deceased relatives carry the most useful information of all, namely the age at diagnosis and the cause of death. Dropping them erases the very pattern the history exists to find. Option d is incorrect because the family history exists precisely to identify risk that the client's own record cannot show. A genogram spanning three generations is what makes a familial cluster visible.

Correct Answer: Help the client sit down and stay present

Symptoms mean the test has already answered its question, so safety comes first. The nurse eases the client back down, stays at the bedside to prevent a fall, and reports the finding. Option a is incorrect because pressing on with the cuff while the client is faint invites a collapse onto the floor. The protocol says to stop the moment symptoms appear, not to finish the number. Option c is incorrect because walking away abandons an unsteady client at the exact moment of greatest risk. Notification matters, but it happens from the bedside or after someone else has taken over. Option d is incorrect because charting can wait while a client is on the verge of fainting. Recording the dizziness is part of the test, yet it follows the move to a safe position.

Correct Answer: Mobility, assessed through gait

Mobility is examined through gait and range of motion. Step length, base of support, arm swing, and smoothness all belong here, and a shuffling gait with reduced arm swing suggests Parkinson disease. Option b is incorrect because body structure records stature, nutritional state, symmetry, and the posture held at rest. A stooped trunk fits there, but the walking pattern that dominates this description does not. Option c is incorrect because physical appearance takes in apparent age, consciousness, skin color, and signs of distress such as accessory muscle use. Nothing in the description points to those observations. Option d is incorrect because grooming sits within behavior alongside speech, mood, and dress. How a client walks says nothing about whether the hair is combed or the nails are cared for.

Correct Answer: Roughly eighty percent of the circumference

A bladder that encircles about four fifths of the arm spreads cuff pressure around the limb evenly, which keeps the force reaching the brachial artery true to what the gauge shows. Option a is incorrect because forty percent belongs to bladder width, the measurement taken across the cuff rather than around the arm. A bladder that short would leave much of the limb uncompressed. Option b is incorrect because sixty percent is not a standard for either cuff dimension. Choosing it would leave a stretch of arm outside the bladder, so pressure would reach the artery unevenly. Option d is incorrect because a bladder wrapping the whole limb overlaps itself and traps the tubing. The standard stops short of full encirclement, leaving room for a secure fastening without a double layer.

Correct Answer: Back supported with feet flat on the floor

A supported back and feet resting flat on the floor keep the reading free of the isometric and postural effects that raise it, and the bared arm is supported level with the heart. Option a is incorrect because an unsupported back adds roughly five to ten points, mostly to the diastolic value. Dangling feet compound that by leaving the legs without support during the measurement. Option c is incorrect because crossing the legs pushes systolic pressure up, and an arm lying in the lap sits below the heart. Two separate distortions would then travel into one number. Option d is incorrect because perching on an examination table leaves the back and the legs unsupported at once. Standard technique moves the client to a chair with a back and a floor underfoot.

Correct Answer: Count the apical rate for one minute

An irregular rhythm cannot be extrapolated from a partial count, so the nurse counts for a full minute and listens at the apex, where every ventricular contraction is heard. Option a is incorrect because doubling a thirty second count assumes the beats are evenly spaced. With an uneven rhythm that assumption breaks down, and the recorded rate can miss the true number by a wide margin. Option b is incorrect because comparing wrists checks arterial symmetry and local circulation, not cardiac rhythm. Both radial pulses will reflect the same irregular heartbeat, so the comparison adds nothing to the rate the nurse needs. Option c is incorrect because carrying forward an earlier value hides a new dysrhythmia that has just appeared. An irregular pulse is a reportable finding, and moving on without measuring it accurately delays recognition.

Correct Answer: Warm the hand and move the probe site

Pulse oximetry needs a strong arterial pulsation, and a cold vasoconstricted finger cannot supply one. Warming the extremity and trying the earlobe or another site corrects the commonest cause of an unobtainable reading. Option a is incorrect because escalating to a rapid response rests on a number the device is not reliably producing. The client's color, alertness, and easy breathing all contradict a saturation in the mid eighties. Option c is incorrect because charting an artifact as though it were a measurement plants a false value in the record. Other clinicians will treat it as real, and the true saturation still remains unknown. Option d is incorrect because a failing battery shuts a monitor down rather than producing a value that tracks with a cold finger. The mottled skin already explains the intermittent signal.

Correct Answer: Readings that are falsely high

A cuff too narrow for the arm must be pumped to a higher pressure before it compresses the brachial artery through the surrounding tissue, so the recorded value exceeds the true arterial pressure. Option b is incorrect because falsely low values come from the opposite mismatch, a cuff that is too wide for the limb. A wide bladder flattens the artery at a lower inflation pressure than the client actually carries. Option c is incorrect because size mismatch never leaves the measurement untouched. Undercuffing a heavy arm is the single commonest measurement error in practice, and it inflates results enough to label a normotensive client hypertensive. Option d is incorrect because narrowing of the pulse pressure reflects a fall in stroke volume, as happens in shock or aortic stenosis. Cuff width shifts both numbers in the same direction rather than squeezing them together.