Exam 10: General Survey

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?

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?

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

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 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?

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?

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?

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

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?

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?

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?

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?