Exam Cram NCLEX RN Practice Questions - Nurselytic

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.

Correct Answer: A

Rationale: When evaluating the temperature of older adults, it is important to note that their body temperature is usually lower than that of younger adults, with a mean temperature of 36.2°C.
Choice B is incorrect because an older adult's body temperature is not approximately the same as that of a young child.
Choice C is incorrect because body temperature is a physiological parameter and does not vary based on the type of thermometer used.
Choice D is incorrect because while older adults may have less effective heat control mechanisms, their body temperature is typically lower, not widely fluctuating.

Correct Answer: A

Rationale: When assessing the force or strength of a pulse, the nurse should recall that it is a reflection of the heart's stroke volume. The heart pumps an amount of blood (the stroke volume) into the aorta, causing arterial walls to flare and generate a pressure wave felt as the pulse in the periphery. The force of the pulse is typically recorded on a 0- to 3-point scale, not a 0- to 2-point scale. The force of the pulse does not demonstrate the elasticity of blood vessel walls or reflect the blood volume in the arteries during diastole.
Therefore, choices B, C, and D are incorrect.

Correct Answer: B

Rationale: Height and weight are the most accurate measurements to assess a child's general health. These measurements reflect the physical growth and development of the child, indicating overall health status.

Choices C and D, head circumference and chest circumference, are important measurements for specific assessments but do not provide as comprehensive an overview of general health as height and weight. Body mass index (BMI) is a calculation based on height and weight, making height and weight more direct and primary indicators of a child's health compared to BMI.

Correct Answer: D

Rationale: When measuring a patient's blood pressure, it is important to consider various factors that influence blood pressure. Peripheral vascular resistance plays a crucial role in regulating blood pressure. The level of blood pressure is affected by factors such as cardiac output, peripheral vascular resistance, volume of circulating blood, viscosity, and elasticity of the vessel walls. Pulse rate (
Choice
A) refers to the number of heartbeats per minute and is not a primary factor influencing blood pressure. Pulse pressure (
Choice
B) is the difference between systolic and diastolic blood pressure and does not directly impact blood pressure regulation. Vascular output (
Choice
C) is not a recognized term in blood pressure regulation and is not a primary factor affecting blood pressure.