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
- 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
- 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
- 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
- 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
- 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
- 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.
- 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.
- 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?”
- 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.
- 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
- 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
- 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
- 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.
- 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
- 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.
- 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.”
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