Deck 10: General Survey

Question 1

During an interview with an older adult client, the nurse notes the client is confused as to day and time. The nurse documents this finding as an indicator of which item?

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

Answer 1

Orientation.

Question 2

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

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

Answer 2

Respirations, apical pulse rate, axillary temperature.

Question 3

The nurse is assessing an older adult client with arteriosclerosis and obtains a blood pressure reading of 172/98 mmHg. Which factors may be applicable in this situation?

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 plays no role in the blood pressure of this client.

Answer 3

Arteriosclerosis decreases blood vessel compliance.
Age decreases blood vessel elasticity.

Question 4

A young adult client presents to the clinic complaining of a sore throat, swollen glands, and fever following oral surgery for extraction of impacted wisdom teeth. In order to complete the initial assessment of this client, the nurse needs to obtain the client's temperature. Which method should the nurse choose for this assessment?

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

Question 5

The nurse educator is preparing an in-service on pain management for the staff. One of the staff nurses asks, "What is the most important part of a pain assessment?" Which response by the nurse educator is the most appropriate?

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 obtaining the initial vital signs on a client in the emergency department (ED) with seizure activity of unknown etiology. Which method is most appropriate for the nurse to use when assessing the client's temperature?

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

Question 7

The nurse is caring for a client diagnosed with breast cancer who underwent a left-sided mastectomy two days prior. The nurse has delegated vital signs on this client to the unlicensed assistive personnel (UAP). What specific instructions should the nurse provide to the (UAP) in delegating this task?

A) Take the blood pressure on the right arm.
B) No special instructions are needed.
C) Take the blood pressure on the left arm.
D) Take the blood pressure on both arms for a baseline.

Question 8

The nurse needs to take a blood pressure on a very thin client, and the only cuff available is a standard size. Which type of blood pressure reading does the nurse expect?

A) An accurate reading.
B) A falsely elevated reading.
C) The reading will depend on the overall health of the client.
D) A false low reading.

Question 9

An older adult client says to the nurse, "I'm gaining weight around my middle and my legs look like chicken legs." Which response by the nurse is the most appropriate?

A) "Older people often put on weight around the middle, but lose muscle in the legs, making the legs appear thinner. This is normal."
B) "Have you been doing any exercises to slim down your middle?"
C) "This is very unusual. I will let the healthcare provider know."
D) "Let's talk about your diet to see why you're gaining weight around your middle."

Question 10

The nurse is assessing a 15-month-old toddler client. Which site is the most appropriate for the nurse to use when assessing the pulse?

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

Question 11

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

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

Question 12

The night nurse is reviewing the vital signs of a client in an extended care facility. The nurse notes the client's oral temperature at 6 a.m. was 98.0°F, but that evening, the client's oral temperature was 99.2°F. What is this variation indicative of?

A) The client's temperature has been improperly assessed either in the morning or evening; the nurse can't be sure which.
B) The client is developing an infection.
C) The client is experiencing stress.
D) The client's temperature is demonstrating diurnal variations.

Question 13

The nurse educator is observing the student nurse take a blood pressure on an older adult client. When is it appropriate for the nurse educator to intervene during this assessment?

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 14

During the evening assessment of a febrile client admitted to the nursing unit with abdominal pain, the nurse assesses a lower than normal blood pressure and a rapid pulse. What is the most likely cause of these findings?

A) Anxiety.
B) An abdominal infection.
C) A medication reaction.
D) A diurnal variation.

Question 15

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

A) A.
B) B.
C) C.
D) D.

Question 16

The nurse is entering the room to assess a newly admitted client. Which best describes the purpose for a general survey that is conducted prior to beginning 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 17

A young adult client notes height as "5 feet 11 inches" and weight as "200 lbs." Upon assessment, the client is found to be 5 feet 9 inches tall with a weight of 225 lbs. Which is the most likely cause of this discrepancy?

A) The client does not have a scale at home.
B) The client may have an image of self that is inconsistent with actual findings.
C) The client did not want to tell the truth.
D) The client is trying to hide a chronic illness.

Question 18

The nurse is assessing a toddler when the child's mother states that the child has had a fever for the past two days. When the nurse asks the mother what the temperature has been, the mother replies that she hasn't actually taken it but the child's skin has felt very warm. Which response by the nurse is appropriate in this situation?

A) "When our skin feels warm, it means our blood vessels are constricted."
B) "The only reliable indicator of body temperature is by feeling the forehead."
C) "Our skin temperature changes when our surroundings change temperature."
D) "The temperature of the skin is not related to what is happening inside our bodies."

Question 19

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) Noting of the number of times the client looks to significant other while answering interview questions.
B) Asking the client to describe elements of his health history.
C) Studying the client's clothing selections.
D) Noticing the client's ability to make eye contact during the examination.

Question 20

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 status.
B) Subjective assessments related to ambulation.
C) Activity tolerance.
D) Strength of upper and lower extremities.

Question 21

An older adult client has edema of the lower extremities despite being prescribed medication for this symptom. Which is the priority nursing intervention for this client?

A) Discussing the finding with the client's healthcare provider.
B) Providing the client with support hose.
C) Reviewing the client's current medications.
D) Documenting the finding in the medical record.

Question 22

The nurse is admitting a client with a fractured hip. The client points to the painful hip and describes it as a constant throbbing. Which would the nurse include when continuing the pain assessment on this client?

A) Intensity, precipitating and relieving factors, impact on ADLs, and coping strategies.
B) Intensity, quality, location, and impact on ADLs.
C) Intensity, quality, pattern, and precipitating factors.
D) Intensity, quality, precipitating and relieving factors, and impact on ADLs.

Question 23

The nursing staff is admitting a client diagnosed with diabetic ketoacidosis (DKA). The licensed practical nurse (LPN) asks the registered nurse (RN) if the pulse oximeter needs to be placed on the client. Which response by the RN to the LPN is the most appropriate?

A) "Please place the pulse oximeter on the client."
B) "I will let you know after I complete my assessment."
C) "Thanks, but that is something I have to do for the client."
D) "We don't have an order to do that."

Question 24

The nurse is assessing a client who has suffered a cerebral vascular accident (CVA or stroke) and has difficulty with verbal expression, but no other deficits. What approach should the nurse use to assess this client's level of pain?

A) The nurse asks the client's family member to place a number on the client's pain using a scale of 0 (no pain) to 10 (most pain), since the family member knows the client best.
B) The nurse considers the client's behavior and vital signs and determines a number from the pain scale (0-10) based on these objective findings.
C) The nurse uses the Wong-Baker "FACES" pain rating scale.
D) The nurse reviews the previous pain assessments and makes a determination based on these findings.

Question 25

During a physical assessment the client asks the nurse repeatedly, "Is everything ok?" The nurse concludes which for this client?

A) A poor self-concept.
B) Inappropriate affect.
C) Confusion.
D) Anxiety.

Question 26

A nurse has been asked to present a program on blood pressure for a group of adults at a community center. Which statement is appropriate for the nurse to include in the program?

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 decreases.

Question 27

A client presents to the primary care clinic and is disheveled in appearance, with stained, dirty clothing, body odor, and uncombed hair. Based on this observation, which topics should the nurse assess during the history and physical exam?

A) Occupation.
B) Depression.
C) Smoking history.
D) Self-concept.
E) Immunization status.

Question 28

The nurse is conducting a general survey on an infant for a health maintenance visit. During the survey, the infant has a liquid stool. The mother becomes very angry and asks the nurse to change the diaper because she just can't "deal with the odor." Why is this mother's statement important to the nurse?

A) The child may have an illness that is causing diarrhea.
B) It may be a reflection of the mother-child relationship.
C) The mother may be feeding the child a poor diet.
D) The child may have an illness that is increasing the odor of stool.

Question 29

The unlicensed assistive personnel (UAP) brings the nurse the following vital signs for an older adult client: Temperature 97.4ºF (oral), BP 165/70, pulse rate 84/min., and respirations 28. After reviewing the vital signs, which action by the nurse is the most appropriate?

A) Continue to monitor the client.
B) Tell the UAP to recheck the temperature.
C) Obtain an order for an antihypertensive.
D) Obtain an order for oxygen therapy.

Question 30

The nurse is conducting a class on hypertension, when a client asks what the numbers in the blood pressure mean. Which statements would the nurse correctly use to answer the client's question?

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 31

While interviewing a client, the nurse observes that the client is changing position frequently, wringing hands, and laughing at inappropriate times. Which would be appropriate for the nurse to include in the assessment based on this information?

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

Question 32

The nurse is obtaining the height and weight of an older adult client. The client asks why the height is 1 inch less than last year. Which response by the nurse is the most appropriate?

A) "Your bones are weaker and are shrinking."
B) "I am sure you are mistaken and just don't remember from last year."
C) "Your height decreases with age due to musculoskeletal changes."
D) "Stand up straighter this time and we will measure again."