Exam 10: General Survey

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?

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?

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?

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 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?

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?

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?

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?

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?

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?

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?

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 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?

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?

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?

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

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?

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?

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?

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?