Ch7 General Survey
- 1.
During the interview with Mr. Miller, the nurse observes his body shape and build. The examiner also notes that he is well nourished and appears his stated age. What component of the general survey has the nurse observed?
- A.
Mental status
- B.
Physical appearance
- C.
Behavior of client
- D.
Mobility
Correct Answer
B. Physical appearanceExplanation
The client’s physical appearance, including facial appearance, body shape and build, and apparent nourishment, provides immediate and important clues to the level of individual wellness.Rate this question:
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- 2.
When the nurse obtains Mr. Miller’s pulse rate, she records it as 106 bpm. When documenting the pulse rate, what term should the nurse use to record an elevated pulse rate?
- A.
Bradycardia
- B.
Thready pulse
- C.
Tachycardia
- D.
Rhythmic pulse
Correct Answer
C. TachycardiaExplanation
Tachycardia is defined as a pulse rate over 100 bpm.Rate this question:
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- 3.
When the nurse is collecting vital signs from Mr. Miller, which of the following would require additional information to determine why it is abnormal? Vital Signs: Temperature – 97.4°F Oxygen saturation – 95% Respiratory rate – 17 Blood pressure – 156/94
- A.
Temperature – 97.4°F
- B.
Oxygen saturation – 95%
- C.
Respiratory rate – 17
- D.
Blood pressure – 156/94
Correct Answer
D. Blood pressure – 156/94Explanation
Based on Mr. Miller’s history of hypertension, this recording is considered to be abnormal.Rate this question:
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- 4.
During the interview with Mr. Miller, the nurse asks the client, “What is today’s date?”. Which component of the general survey is the nurse assessing?
- A.
Mental status
- B.
Physical appearance
- C.
Mobility
- D.
Age-related considerations
Correct Answer
A. Mental statusExplanation
When the nurse assesses the mental status of the client, the nurse is observing mood, level of anxiety, orientation, and speech.Rate this question:
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- 5.
During the interview with Mr. Miller, the nurse assesses his activities including walking into the room, his introduction with the examiner, and his facial expressions. When the nurse assesses these activities, she is examining the functional assessment.
- A.
True
- B.
False
Correct Answer
A. TrueExplanation
During the general survey of the client, the nurse will observe the client performing the following common activities: walking into the examination room, taking a seat for the interview, and moving the arms and hands to arrange clothing or to shake hands as an introduction.Rate this question:
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- 6.
The nurse notices that a client walks with a limp and has long legs. Which of the following aspects of the general survey is this nurse assessing?
- A.
Physical appearance
- B.
Mental status
- C.
Mobility
- D.
Behavior
Correct Answer
C. MobilityExplanation
The nurse observes the client’s gait, posture, and range of motion when assessing mobility in the general survey.
Physical appearance, mental status, and behavior are the other components of the general survey. Difficulty with gait and posture, such as limping, calls for further evaluation.Rate this question:
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- 7.
During an admission assessment on a 79-year-old client, the nurse learns the client has been taking four different medications, all for the same health condition. What should the nurse do with this information?
- A.
Document it in the medical record.
- B.
Contact the primary care physician.
- C.
Send an order for the medications to the pharmacy.
- D.
Nothing. This is typical for clients in this age range.
Correct Answer
B. Contact the primary care physician.Explanation
Older adults often consume several prescription medications. Overmedication may occur because older adults seek care from multiple health care providers without collaboration regarding treatment. Multiple medications for the same condition may combine to produce dangerous side effects.
The nurse would document the medications in the medical record; however, the priority intervention is to call the physician and verify that they are aware of the situation.
Sending an order to the pharmacy and doing nothing are not appropriate.
The nurse needs more information about the prescribed medications.Rate this question:
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- 8.
Prior to measuring a client’s height and weight, the client states, “I am 5 feet 10 inches tall and weigh 160 pounds.” Upon assessment, the nurse finds the client is shorter and weighs 15 pounds more. What can the nurse surmise from this finding?
- A.
The client might have a self-image disturbance.
- B.
The client is lying.
- C.
The client is embarrassed about his/her weight.
- D.
The client hasn’t been weighed or measured in a long time.
Correct Answer
A. The client might have a self-image disturbance.Explanation
Discrepancies between the stated height and weight and the actual measurements may provide clues to the client’s self-image.
Not enough information is provided to determine if the client is lying, is embarrassed about their height and weight, or has not had a height and weight assessment recently.
Discrepancies in weight may also indicate the client’s lack of awareness of sudden weight change that may be due to illness.Rate this question:
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- 9.
A client tells the nurse, “It’s okay that I’m 20 pounds overweight. Everyone in my family is much fatter.” Which of the following would be the best response for the nurse to make at this time?
- A.
“Being overweight contributes to the development of diabetes.”
- B.
“Do your family members have health problems related to being overweight?”
- C.
“Being the lightest in your family must make you feel good.”
- D.
“How do you feel about being 20 pounds overweight?”
Correct Answer
D. “How do you feel about being 20 pounds overweight?”Explanation
The client is overweight and is attempting to rationalize it by comparing herself with other family members. The fact is, the client is overweight, and the nurse needs more information on the client’s feelings about this fact before educating the client on the risks of being overweight and obtaining family history.Rate this question:
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- 10.
A client is brought into the emergency department after being rescued from a major motor vehicle accident. The nurse notes that the client’s body temperature is 99.6°F. The nurse realizes that this finding might suggest:
- A.
The temperature elevation is due to a diurnal variation.
- B.
The client is ovulating.
- C.
The client is stressed.
- D.
The client has an underlying illness not yet diagnosed.
Correct Answer
C. The client is stressed.Explanation
The most reasonable cause for the temperature elevation is stress. The temperature of a highly stressed client may be elevated as a result of increased production of epinephrine and norepinephrine, which increase metabolic activity and heat production.
Core body temperature that is highest in the late evening and lowest in the early morning is an example of diurnal temperature variations.
Ovulation can raise body temperature by as much as 0.5°F. This question doesn’t identify the gender of the client.
There is nothing to suggest that this client had an underlying infection or illness prior to the injury.Rate this question:
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- 11.
The nurse is preparing to measure the temperature of a client with an endotracheal tube. Which method of temperature measurement should the nurse use for this client?
- A.
Tympanic
- B.
Rectal
- C.
Axillary
- D.
Oral
Correct Answer
A. TympanicExplanation
The tympanic temperature measures a client’s core body temperature quickly and accurately. This method is the most comfortable and least invasive for the client.
Rectal temperatures are used in clients who are comatose, confused, or unable to close their mouth. However, in these situations a tympanic temperature could be used and is less invasive.
An oral temperature should not be used on this client because of the endotracheal tube and the inability to close the mouth.
The axillary temperature is the least accurate of the temperature methods and isn’t indicated since a tympanic device is available.Rate this question:
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- 12.
A client has just walked the length of the hallway as part of her prescribed physical therapy program. When the nurse immediately assesses this client’s apical pulse, the finding will most likely be:
- A.
A reduced heart rate
- B.
An elevated heart rate
- C.
A heart rate that is the same as her resting heart rate
- D.
An irregular heart rate
Correct Answer
B. An elevated heart rateExplanation
The pulse rate will normally increase with exercise. This client just walked down the hall as part of the prescribed physical therapy program.
A reduced heart rate might be assessed if the client was at rest.
The heart rate should be higher than the resting heart rate due to exercise.
Exercise should not produce irregularities in the rhythm of the pulse.Rate this question:
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- 13.
The nurse is assessing the respiratory rate of a 35-year-old male client. Which of the following would indicate a normal finding for this client?
- A.
Respiratory rate of 30 to 80 per minute
- B.
Respiratory rate of 20 to 40 per minute
- C.
Respiratory rate of 15 to 20 per minute
- D.
Respiratory rate of 8 to 10 per minute
Correct Answer
C. Respiratory rate of 15 to 20 per minuteExplanation
The normal respiratory rate of adults is between 15 and 20 per minute.
Respiratory rates of 30–80 per minute are the normal range for newborns.
Respiratory rates of 20–40 per minute are considered normal for ages up to 1 year.
A respiratory rate of 8–10 per minute is abnormally slow respirations for any age group.Rate this question:
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- 14.
The nurse finds the blood pressure reading for a 75-year-old female to be 88/60. Which of the following should the nurse do first after measuring this blood pressure?
- A.
Ensure that the correct cuff size was used to measure this blood pressure.
- B.
Place the client in a standing position.
- C.
Call the physician.
- D.
Nothing. Extremely low blood pressures are normal in the elderly.
Correct Answer
A. Ensure that the correct cuff size was used to measure this blood pressure.Explanation
The bladder of the blood pressure cuff must fit the length and width of the client’s limb. A cuff that is too narrow will produce a false high reading. Conversely, if the cuff is too wide, the reading will be falsely low. If the blood pressure is low, lowering the head of the bed, or placing the client in a supine position is recommended.
Standing may further lower the blood pressure. The nurse needs to verify that this blood pressure measurement was correct and gather more assessment data before calling the physician.
Low blood pressures are not normal in the elderly. With age, blood pressure tends to rise.Rate this question:
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- 15.
The nurse is measuring an adult client’s blood pressure and hears Korotkoff sounds. Which sound should the nurse recognize as being the diastolic measurement for this client?
- A.
Phase 1
- B.
Phase 3
- C.
Phase 4
- D.
Phase 5
Correct Answer
D. Phase 5Explanation
In adults, the diastolic pressure (Phase 5) is the point at which the sounds become inaudible.
Phase 1 sounds are the first sounds heard and signify systolic blood pressure.
Phase 3 is the period in which the sounds are louder. Phase 2 is the period during which the sounds are softer and longer.
Phase 4 is the period during which the sounds become muffled.Rate this question:
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- 16.
During a health interview of a client with residual radiculopathic pain after spinal surgery, the nurse learns that the client holds a full-time job, is married, and does at least half of the routine household activities. From this information, the nurse can accurately document:
- A.
The client takes pain medication routinely.
- B.
The pain doesn’t interfere with normal activities of daily living.
- C.
The client uses work to cope with the pain.
- D.
The client is stoic.
Correct Answer
B. The pain doesn’t interfere with normal activities of daily living.Explanation
Assessment of the impact of pain on ADLs enables the nurse to understand the severity of the pain and the impact of the pain on the client’s quality of life.
There is not enough information to determine whether the client takes pain medication on a “routine” basis.
Based on what the client has described as routine ADLs, the nurse can accurately document that the pain doesn’t interfere with this client’s normal activities.
There is no information that implies that the client uses work to cope with the pain or is stoic.Rate this question:
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- 17.
An elderly client comes into the pain clinic for follow-up care. The nurse notices that the client grimaces with position changes and continues to have difficulty walking. From this observation, which of the following would be appropriate for the nurse to say to this client?
- A.
“Tell me what your pain level is right now.”
- B.
“I see that you are moving better.”
- C.
“Did you stop taking your pain medication again?”
- D.
“The doctor isn’t going to be happy to see how much pain you are in.”
Correct Answer
A. “Tell me what your pain level is right now.”Explanation
A variety of behaviors indicate the presence of pain. Many of these behaviors are nonverbal such as grimacing.
The nurse would be wise to ask the client about the level of pain instead of making comments that are clearly contrary to observation such as stating that the client is moving better or assuming that the client stopped taking the pain medication.
Using the physician as a threat is not using therapeutic communication techniques.Rate this question:
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Current Version
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Mar 22, 2023Quiz Edited by
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Sep 11, 2012Quiz Created by
Shinichiro
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