Deck 8: General Survey and Physical Exam: Objective Data

Question 1

A mother brings her child into the clinic and states, "My child has had a fever the past few days because the skin has felt warm." Which response should the nurse provide the mother?

A) "When the skin feels warm, it means our blood vessels are constricted."
B) "The only way to reliably assess the temperature with your hand is by feeling the forehead."
C) "The skin temperature changes when the temperature in our surroundings changes."
D) "The temperature of the skin is not related to what is occurring inside the body."

Answer 1

"The skin temperature changes when the temperature in our surroundings changes."

Question 2

The nurse is preparing to assess a client's mental status within the general survey. Which data should the nurse use to assess this status?

A) Observation of the client ambulating.
B) Asking the client to describe elements of his health history.
C) Observation of the client's clothing selections.
D) Observation of eye contact during the examination.

Answer 2

Asking the client to describe elements of his health history.

Question 3

The nurse is obtaining vital signs for a newborn client. Which route and sequence will the nurse use to obtain vital signs?

A) Rectal temperature, respirations, and pulse rate.
B) Respirations, pulse rate, blood pressure, and rectal temperature.
C) Respirations, apical pulse rate, and axillary temperature.
D) Oral temperature, respirations, pulse rate, and blood pressure.

Answer 3

Respirations, apical pulse rate, and axillary temperature.

Question 4

The nurse is assessing a 15-month-old client. Which arterial site should the nurse use to assessing the pulse?

A) Radial artery.
B) Brachial artery.
C) Apical site.
D) Carotid artery.

Question 5

The new nurse asks the educator, "What is the most important part of a pain assessment?" Which response should the nurse educator provide?

A) "Pain is only partially subjective and primarily a physiologic experience, so vital signs are the most important assessment."
B) "A client's response to pain is always based on the underlying cause, so the client's admitting diagnosis is important."
C) "Vital signs are not reliable indicators of acute pain because only some clients are able to elicit a change in blood pressure or pulse rate."
D) "The response to pain is unique and based on numerous factors, which need to be assessed."

Question 6

The nurse is preparing to obtain a pulse oximeter reading. Which should the nurse understand may provide a false reading? Select all that apply.

A) Long nails.
B) Artificial nails.
C) Pierced earlobe.
D) Polished nails.
E) Cool extremities.

Question 7

During the assessment of an adult client's blood pressure, the nurse notes the following on the sphygmomanometer: first faint tapping sounds at 136, swishing sounds at 120, clear tapping sounds at 108, muffled sounds at 98, and silence at 76. Which should the nurse document the client's blood pressure in this way? ________. Record your answer as a fraction.

Question 8

The nurse is preparing to assess the blood pressure of a client with a history of a left breast mastectomy. Which anatomical location should the nurse use to place the blood pressure cuff on?

A) Right arm.
B) Left thigh.
C) Left arm.
D) Right thigh.

Question 9

The nurse is preparing to obtain initial vital signs on a client with seizure activity of unknown etiology. Which method should the nurse use to obtain the temperature?

A) Axillary.
B) Oral.
C) Rectal.
D) Tympanic.

Question 10

The nurse is preparing to conduct a general survey. Which should the nurse recognize is the purpose of performing the general survey prior to the physical assessment?

A) Allows for vital signs prior to starting exam.
B) Provides an opportunity for the client to relax before the exam.
C) Yields information to guide the physical assessment.
D) Provides the information necessary for the diagnosis.

Question 11

The nurse is preparing to measure the head circumference of an infant. Which technique should the nurse use?

A) Measure the head directly circumferentially around the forehead.
B) Measure the head around the occiput and above the eyebrows.
C) Measure around the most prominent part of the occiput and above the eyebrows.
D) Measure the crown of the head circumferentially.

Question 12

The nurse observes the client walking into the room and climbing up on the exam table. The nurse notes this activity to obtain data related to which item?

A) Mobility.
B) Balance.
C) Activity tolerance.
D) Strength of upper and lower extremities.

Question 13

The nurse is assessing an adult client's pulse. Which method should the nurse initially use?

A) Monitoring for a full 2 minutes.
B) Monitoring for 1 complete minute.
C) Monitoring for 30 seconds and multiply by 2.
D) Monitoring for 15 seconds and multiply by 4.

Question 14

The nurse is preparing to weigh a client on a digital scale. Which intervention should the nurse implement to obtain an accurate weight?

A) Calibrate the scale.
B) Ensure the scale has a capacity to hold greater than 159 kg.
C) Ask the client to remove their shoes.
D) Have the client stand on the scale facing backward.

Question 15

The nurse is assessing a client's left brachial pulse. Which area will the nurse palpate to?

A) Wrist.
B) Behind the knee.
C) Cubital fossa.
D) Neck.

Question 16

The nurse is assessing an older adult client with arteriosclerosis and obtains a blood pressure reading of 172/98 mmHg. Which physiological changes should the nurse recognize are associated with the blood pressure finding? Select all that apply.

A) Arteriosclerosis decreases the ventricular force necessary for ejection of blood.
B) Arteriosclerosis increases blood vessel elasticity.
C) Arteriosclerosis decreases blood vessel compliance.
D) Age decreases blood vessel elasticity.
E) Arteriosclerosis does not affect the blood pressure in older clients.

Question 17

A client is unable to identify the correct date and time during a health interview. Which indicator should the nurse document the finding as?

A) Affect and mood.
B) Orientation.
C) Cooperation.
D) Level of anxiety.

Question 18

The nurse is preparing to assess the temperature of a child post oral surgery suspected of having an infection. Which route should the nurse use?

A) Oral.
B) Tympanic.
C) Rectal.
D) Axillary.

Question 19

The nurse educator is observing the student nurse take a blood pressure on an older adult client. In which instances should the educator intervene? Select all that apply.

A) The student nurse ushers the client into the exam room and immediately assesses the client's blood pressure.
B) The student nurse places the blood pressure cuff on the client's arm over a lightweight, long-sleeved sweater.
C) The student nurse immediately reinflates the cuff after identifying the palpatory systolic blood pressure.
D) The student nurse has the client sit in a chair and supports the client's arm on a table at the level of the heart.
E) The student nurse places the blood pressure cuff on the thigh of a client with a bilateral mastectomy and takes the blood pressure using the popliteal artery.

Question 20

The nurse is assessing an adult client. Which observations should the nurse include when documenting the general survey of this client? Select all that apply.

A) Blood pressure 112/68, pulse 68, 98.6°F, and respiratory rate 16.
B) Thin, well-nourished male client appears younger than stated age.
C) Client ambulatory without difficulty.
D) Abdomen flat, nondistended, bowel sounds present, and nontender on palpation.
E) Pain rating of 3 on a 0 to 10 scale.

Question 21

While interviewing a client, the nurse observes that the client is changing position frequently, wringing hands, and laughing at inappropriate times. Which assessment should the nurse perform?

A) Anxiety assessment.
B) Mental status testing.
C) Attention deficit testing.
D) Nutritional assessment.

Question 22

The nurse is providing education about blood pressure for a group of clients. Which information should the nurse include?

A) Females tend to have higher blood pressure readings than males of the same age.
B) Stress can result in an increase in blood pressure.
C) Blood pressure readings tend to be lowest in the evening.
D) During physical activity, blood pressure can slightly decrease.

Question 23

A client asks what the numbers in the blood pressure mean. Which statements should the nurse include in the response to the client? Select all that apply.

A) "Diastolic pressure, indicated by the bottom number, is the pressure in the arteries when the heart is at rest."
B) "Diastolic pressure is the arterial pressure between ventricular contractions."
C) "Systolic pressure, indicated by the top number, is the result of the heart rate."
D) "Systolic pressure, indicated by the top number, reflects the pressure in the arteries when the heart contracts and pumps blood into general circulation."
E) "Systolic pressure is the pressure at the height of the wave, when the left ventricle contracts."

Question 24

The nurse is preparing to obtain an adult client's temperature with a tympanic thermometer. Which technique should the nurse use to obtain an accurate reading?

A) Pull the client's pinna up and back.
B) Pull the client's pinna down and back.
C) Place the covered probe at the opening of the ear.
D) Tilt the client's head to the opposite side.

Question 25

An unlicensed assistive personnel (UAP)reports an older adult's vital signs to nurse as follows: Temperature 97.4°F (oral), BP 165/70, pulse rate 84/min., and respirations 28. Which action should the nurse take?

A) Maintain routine vital signs.
B) Instruct the UAP to recheck the temperature.
C) Request a prescription for an antihypertensive.
D) Request oxygen therapy.

Question 26

The nurse notes the client's oral temperature at 6 a.m. was 98.0°F and 99.2°F at 5:00 pm. Which should the nurse recognize is the reason for the variation?

A) Improper assessment.
B) Infection.
C) Stress.
D) Diurnal pattern.

Question 27

The educator has observed the nurse taking the blood pressure with the client's arm above the level of the heart. Which assessment finding does the educator anticipate?

A) False low reading.
B) False high reading.
C) High systolic, low diastolic reading.
D) Low systolic, high diastolic reading.

Question 28

The nurse is preparing to assess the respiratory system of an infant. Which physiological differences between the infant and a child should the nurse consider?

A) Infants have thicker muscular chest walls.
B) Breath sounds may be more subtle.
C) Thoracic breathing is common.
D) Referred sounds from the upper airways are common.

Question 29

The nurse is reviewing the prescription for a client with pneumonia. The client's vital signs are: Temperature 101.2°F (oral), BP 100/70, pulse rate 110/min., respirations 22, and oxygen saturation 96%. Based on these findings, which order should the nurse seek clarification for?

A) Administer acetaminophen (Tylenol)650 mg every 4 hours as needed for a temperature greater than 100.5°F.
B) Administer intravenous (IV)fluids: 0.9% Normal Saline Solution at 125 ml/hour.
C) Start oxygen therapy at 3L/minute via nasal cannula.
D) Schedule client for a chest x-ray.

Question 30

The nurse observes that an adolescent client is wearing dirty clothes. Which initial risk factor should the nurse further assess the client for?

A) Substance abuse.
B) Lack of hygiene knowledge.
C) Neglect.
D) Low self-esteem.

Question 31

An older client asks why their height has decreased by 1/4 of inch over past two years. Which response should the nurse provide?

A) "Your bones are weaker and are shrinking."
B) "Maybe you are mistaken about your actual height."
C) "Your height decreases with age due to musculoskeletal changes."
D) "Stand up straighter this time and we will measure again."