Exam 7: General Survey

The nurse is assessing a 15-month-old baby.The nurse should assess this baby's pulse rate by using the:

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?

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?

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?

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?

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:

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?

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?

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 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.

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?

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?

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?

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:

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:

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?

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?

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?

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?

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?