Deck 7: General Survey

Question 1

The nursing instructor is observing the student nurse take a blood pressure on an older adult client.The nursing instructor intervenes when the student nurse is observed doing which of the following?
1)The student nurse ushers the client into the exam room and immediately assesses the client's blood pressure.
2)The student nurse places the blood pressure cuff on the client's arm over a lightweight,long-sleeved sweater.
3)The student nurse immediately reinflates the cuff after identifying the palpatory systolic blood pressure.
4)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.
5)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.

Answer 1

1,2,3

Question 2

The nurse is obtaining the initial vital signs on a client in the emergency room with seizure activity of unknown etiology.The nurse should choose which of the following methods to obtain the most accurate reading of the client's temperature?
1)Axillary
2)Oral
3)Rectal
4)Tympanic

Answer 2

3

Question 3

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?
1)Oral
2)Tympanic
3)Rectal
4)Axillary

Answer 3

2

Question 4

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.These findings suggest to the nurse that the client may be experiencing:
1)anxiety.
2)an abdominal infection.
3)a medication reaction.
4)a diurnal variation

Question 5

The nurse educator is preparing an inservice on pain management for the staff.One of the staff nurses asks,"What is the most important part of a pain assessment?" How should the nurse educator respond to this question?
1)"Pain is only partially subjective and primarily a physiologic experience,so vital signs are the most important assessment."
2)"A client's response to pain is always based on the underlying cause,so the client's admitting diagnosis is important."
3)"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."
4)"The response to pain is unique and based on numerous factors,which need to be assessed."

Question 6

During an interview with an older adult client,the nurse notes the client is confused as to day and time.The nurse would document this finding as an indicator of which of the following?
1)Affect and mood
2)Orientation
3)Willingness to cooperate
4)Level of anxiety

Question 7

The nurse is entering the room to assess a newly admitted client.Which of the following best describes the purpose for a general survey? The general survey:
1)allows for vital signs prior to starting exam.
2)provides an opportunity for the client to relax before the exam.
3)yields information to guide the physical assessment.
4)provides the information necessary for the diagnosis.

Question 8

The nurse is assessing a 15-month-old baby.The nurse should assess this baby's pulse rate by using the:
1)Radial artery.
2)Brachial artery.
3)Apical site.
4)Carotid artery.

Question 9

The nurse is assessing an older adult client with arteriosclerosis and obtains a blood pressure reading of 172/98.The nurse understands that the following factors may be applicable in this situation.
1)Arteriosclerosis decreases the ventricular force necessary for ejection of blood.
2)Arteriosclerosis increases blood vessel elasticity.
3)Arteriosclerosis decreases blood vessel compliance.
4)Age decreases blood vessel elasticity.
5)Arteriosclerosis plays no role in the blood pressure of this client.

Question 10

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 patient care assistant (PCA).What specific instructions should the nurse provide to the (PCA)in delegating this task?
1)Take the blood pressure on the right arm.
2)No special instructions are needed.
3)Take the blood pressure on the left arm.
4)Take the blood pressure on both arms for a baseline.

Question 11

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.The nurse identifies the most likely reason for this discrepancy between the client's self-reported height and weight and the objective information indicates:
1)The client does not have a scale at home.
2)The client may have a image of self inconsistent with actual findings.
3)The client did not want to tell the truth.
4)The client is trying to hide a chronic illness.

Question 12

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.This nurse would document this client's blood pressure as_____________.

Question 13

The nurse is assessing an adult client.Which of the following observations should the nurse include when documenting the general survey of this client?
1)Blood pressure 112/68,pulse 68,98.6 (F),respiratory rate 16.
2)Thin,well-nourished male client,appears younger than stated age.
3)Client moves about exam room without difficulty.
4)Abdomen flat,nondistended,bowel sounds present,nontender on palpation.
5)Responds appropriately to questions.

Question 14

The nurse is caring for a pediatric client and needs to obtain vital signs.Which of the following route and sequence will the nurse use to obtain vital signs on a healthy newborn?
1)Rectal temperature,respirations,pulse rate
2)Respirations,pulse rate,blood pressure,rectal temperature
3)Respirations,apical pulse rate,axillary temperature
4)Oral temperature,respirations,pulse rate,blood pressure

Question 15

The nurse observes the client walking into the room and climbing up on the exam table.The nurse notes this activity as a way to obtain data related to which of the following?
1)The client's mobility status
2)Subjective assessments related to ambulation
3)Activity tolerance
4)Strength of upper and lower extremities

Question 16

The nurse is assessing a toddler when the child's mother tells the nurse 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 of the following would be the most appropriate response for the nurse?
1)"When our skin feels warm,it means our blood vessels are constricted."
2)"The only reliable indicator of body temperature is by feeling the forehead."
3)"Our skin temperature changes when our surroundings change temperature."
4)"The temperature of the skin is not related to what is happening inside our bodies."

Question 17

An older adult client says to the nurse,"I'm gaining weight around my middle and my legs look like chicken legs." An appropriate response by the nurse to this client is:
1)"Older people often put on weight around the middle,but lose muscle in the legs,making the legs appear thinner.This is normal."
2)"Have you been doing any exercises to slim down your middle?"
3)"This is very unusual.I will let the healthcare provider know."
4)"Let's talk about your diet to see why you're gaining weight around your middle."

Question 18

The nurse is assessing a client's left femoral pulse.Identify the area on the diagram below where the nurse would locate this pulse.

Question 19

The nurse needs to take a blood pressure on a very thin client,and the only cuff available is a standard size.The nurse would anticipate which of the following readings?
1)An accurate reading
2)A falsely elevated reading
3)The reading will depend on the overall health of the client
4)A false low reading

Question 20

The nurse is preparing to assess a client's mental status within the general survey.Which of the following should the nurse use to assess this status?
1)Note the number of times the client looks to significant other while answering interview questions.
2)Ask the client to describe elements of his health history.
3)Study the client's clothing selections.
4)Notice the client's ability to make eye contact during the examination.

Question 21

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.The nurse suspects that this variation in temperature is indicative of:
1)The client's temperature has been improperly assessed either in the morning or evening;the nurse can't be sure which.
2)The client is developing an infection.
3)The client is experiencing stress.
4)The client's temperature is demonstrating diurnal variations.

Question 22

The nurse is doing a general survey on an infant for a well-child check.During the survey,the baby 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." This response is important to the nurse because:
1)the child may have an illness causing diarrhea.
2)it may be a reflection of the mother-child relationship.
3)the mother may be feeding the child a poor diet.
4)the child may have an illness that is increasing the odor of stool.

Question 23

The nurse is conducting a class on hypertension,when a client asks what the numbers in the blood pressure mean.Which of the following statements would the nurse correctly use to answer the client's question?
1)"Diastolic pressure,indicated by the bottom number,is the pressure in the arteries when the heart is at rest."
2)"Diastolic pressure is the arterial pressure between ventricular contractions."
3)"Systolic pressure,indicated by the top number,is the result of the heart rate."
4)"Systolic pressure,indicated by the top number,reflects the pressure in the arteries when the heart contracts and pumps blood into general circulation."
5)"Systolic pressure is the pressure at the height of the wave,when the left ventricle contracts."

Question 24

During a physical assessment the client asks the nurse repeatedly,"Is everything ok?" The nurse believes this client is demonstrating:
1)A poor self-concept.
2)Inappropriate affect.
3)Confusion.
4)Anxiety.

Question 25

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 of the following should the nurse assess during the history and physical exam?
1)Occupation
2)Depression
3)Smoking history
4)Self-concept
5)Immunization status

Question 26

The nurse in interviewing a client observes changing of position frequently,wringing hands,and laughing at inappropriate times.Which of the following would be appropriate for the nurse to include in the assessment based on this information?
1)Anxiety assessment
2)Mental status testing
3)Attention deficit testing
4)Nutrition assessment

Question 27

The nurse is admitting a client with a fractured hip.The client points to the painful hip and describes it as a constant throbbing.The nurse would include which of the following when continuing the pain assessment on this client?
1)Intensity,precipitating and relieving factors,impact on ADLs,and coping strategies
2)Intensity,quality,location,and impact on ADLs
3)Intensity,quality,pattern,and precipitating factors
4)Intensity,quality,precipitating and relieving factors,and impact on ADLs

Question 28

The nursing staff is admitting a client diagnosed with diabetic ketoacidosis (DKA).The LPN asks the RN if the pulse oximeter needs to be placed on the client.What is the nurse's best response to the LPN?
1)"Please place the pulse oximeter on the client."
2)"I will let you know after I complete my assessment."
3)"Thanks,but that is something I have to do for the client."
4)"We don't have an order to do that."

Question 29

The nurse is assessing a client who has had 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?
1)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.
2)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.
3)The nurse uses the Wong-Baker "FACES" pain rating scale.
4)The nurse reviews the previous pain assessments and makes a determination based on these findings.

Question 30

The nursing assistant 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,the nurse should do which of the following?
1)Continue to monitor the client.
2)Tell the nursing assistant to recheck the temperature.
3)Obtain an order for an antihypertensive.
4)Obtain an order for oxygen therapy.

Question 31

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.What is the best response by the nurse?
1)"Your bones are weaker and are shrinking."
2)"I am sure you are mistaken and just don't remember from last year."
3)"Your height decreases with age due to musculoskeletal changes."
4)"Stand up straighter this time and we will measure again."

Question 32

An older adult client has edema of the lower extremities despite being prescribed medication for this symptom.Which of the following should the nurse do first to assist this client?
1)Discuss the finding with the client's healthcare provider.
2)Provide the client with support hose.
3)Review the client's current medications.
4)Document the finding in the medical record.

Question 33

A nurse has been asked to present a program on blood pressure for a group of adults at a community center.Which of the following true statements should the nurse incorporate into the presentation?
1)Females tend to have higher blood pressure readings than males of the same age.
2)Middle-aged African American males tend to have higher blood pressures than American males of European descent.
3)Stress can result in an increase in blood pressure.
4)Blood pressure readings tend to be lowest in the evening.
5)During physical activity,blood pressure decreases.