ATI General Survey

stronger radial pulse on left compared to right

Which of the following is considered an unexpected finding for a 40-year-old client's pulse? a. Brisk pulse strength of +2 B. Equal time space between each pulsation C. Pulse rate of 95/min D. Stronger radial pulse on left compared to right

Stomatitis

painful swelling and sores inside the mouth

Fasciculation

rapid continuous twitching of resting muscle without movement of limb

The client takes a narcotic pain medication for chronic pain

A nurse assesses a client's respiratory rate and notes that it is below the expected reference range. The nurse should identify what finding that could cause a decreased respiratory rate?

Visceral

A nurse is assessing a client who is admitted with abdominal pain. The client reports that the pain is "in the stomach and is a crappy, dull ache." What type of pain should the nurse identify this client is experiencing?

Client's clothing; client's speech

A nurse is assessing a client's behavior during the initial survey. What does the nurse include in this assessment?

Tachypnea

A nurse is assessing a client's respirations and notes they are shallow and at a rate of 24/min. The nurse should identify this as what unexpected findings?

25.7

A nurse is calculating the BMI for a client who weighs 150lb and is 5ft 4 in. What is the BMI?

The client reports that the pain has been present for approx 4 years; never feeling total relief from the pain; is recurring and does not always originate in the same location

A nurse is caring for a client who is reporting pain as 4 on a scale of 1 - 10. Upon further assessment, what findings should the nurse identify as manifestations of chronic pain?

Rectal

A nurse is caring for a middle adult client who has stomatitis and is unable to hold an oral probe in their mouth. What alternative route should the nurse use to obtain the most accurate core temperature of the client?

Dirty clothing Unexplained physical injuries Malnourished appearance

A nurse is completing an initial assessment checklist on an older adult client. The client is accompanied by their caregiver. What indicators should the nurse observe when assessing for potential maltreatment of the client?

Fasciculation

A nurse is conducting a general survey on a client and notes a continuous twitching movement of a muscle in the client's left arm. What term should the nurse use to describe this involuntary movement?

The client reports they feel sad and lonely most of the time.

A nurse is conducting a general survey on a client who is being admitted to a long-term care facility. The nurse is assessing the client's emotional state. What finding should the nurse record as a subjective, unexpected finding?

Oxygen saturation 96% on 2L O2 via nasal cannula

A nurse is documenting a client's vital signs in the medical record following a general survey. What entry should the nurse place in the record?

Use of assistive devices height and weight Behavior and mood

A nurse is documenting information in a client's medical record during an initial assessment. What information should the nurse include in the documentation?

Recent scan with contrast dye

A nurse is having difficulty obtaining a pulse oximetry reading from a client. The nurse should identify that what factor can interfere with obtaining a pulse oximetry reading?

Forehead Bridge of nose Earlobe

A nurse is measuring the oxygen saturation of a client who has cyanosis of the extremities. Using a pulse oximeter, where does the nurse place the sensor probe?

60

A nurse is measuring the respiratory rate of a client who has an irregular breathing pattern. For how many seconds should the nurse count the client's respirations?

Tachycardia

A nurse is obtaining a client's pulse and notes a regular rhythm with a rate of 110/min. The nurse should identify this as what unexpected finding?

Cyanosis is noted on fingers

A nurse is performing an initial assessment on a client's skin. What observation will require further assessment on the client's circulation?

Obese

A nurse is performing an initial survey on a client and calculates a BMI of 31 kg/m2. The nurse classifies this client in what weight range?

Ensure the client's feel are in contact with the wall or measuring pole

A nurse is preparing to obtain a client's height during a general survey. What action should the nurse take?

Ensure the client's feet are in contact with the wall or measuring pole

A nurse is preparing to obtain a client's height during a general survey. What action should the nurse take?

Time of day Obesity Diuretic medication Smoking

A nurse is providing teaching to a client who asks, "What are things that can affect my blood pressure?" What information should the nurse include as factors that affect blood pressure?

Tachypnea

A nurse is reviewing the vital signs for a client who has admitted with shortness of breath. The nurse notes the client's respiratory rate is 24/min. The nurse should use what term when documenting this finding?

Lubricate the probe cover Inserts the probe into the rectum 1 to 1.5 in

A nurse is taking a rectal temperature on a client. What actions does the nurse perform?