ATI Heath Assess General Survey

A nurse is preparing to obtain a client's height during a general survey. Which of the following actions should the nurse take? Deduct the client's shoe height from the measurement. Have the client gently lift their chin and look toward the ceiling. Ensure the client's feet are in contact with the wall or measuring pole. Pull up the measuring pole and extend the headpiece after the client

Ensure the client's feet are in contact with the wall or measuring pole. Rationale: The nurse should ensure that the client's feet, shoulders, and buttocks are in direct contact with the measuring pole or against the wall if the stadiometer is a wall-mounted device.

A nurse is planning to obtain orthostatic blood pressures from a client who has syncope. In what order should the nurse complete the steps?

Place the client in a supine position and allow them to rest, take the client's blood pressure in the supine position, keep the cuff in place and assist the client to a seated position, take the client's blood pressure in a seated position, assist the client to stand and then obtain their blood pressure.

While conducting a general survey on a client who is being admitted to a long-term care facility, a nurse is assessing the client's emotional state. Which of the following finding should the nurse record as an unexpected finding? The client is sitting in a relaxed posture. The client is cooperative in answering the nurse's questions. The client tells the nurse that visits from their friends and family make them smile. The client reports they feel sad and lonely most of the time.

Rationale: The nurse should record this statement as an unexpected finding.

A nurse is caring for an adult client who is comatose. Which of the following routes should the nurse use to obtain the most accurate core body temperature of the client? Axillary Temporal Tympanic Rectal

Rectal Rationale: Rectal temperatures are considered the most accurate method for obtaining a client's core body temperature.

A nurse assess a client's respiratory rate and notes that it is below the expected reference range. The nurse should identify that which of the following findings can decrease a client's respiratory rate? The client has been a chronic smoker for 10 years. The client takes a narcotic pain medication for chronic pain. The client reports anxiety due to being in the hospital. The client has a history of anemia.

The client takes a narcotic pain medication for chronic pain. Rationale: Some medications for pain, such as narcotics and opioid analgesics, can depress the rate as well as the depth of respirations due to depressing the central nervous system.

A nurse is caring for a client who is experiencing severe pain. Which of the following client statements indicates that the client is experiencing chronic pain? Select all that apply. The pain from my car accident 2 months ago will not go away." "I still have pain since the surgery last month, but it is getting better." "The pain has been off and on for about a year now." "The pain isn't always in the same place." "I have had this pain for 9 months."

"I've had this pain for 9 months.", "The pain isn't always in the same place", "The pain has been off and on for about a year now" Rationale: Pain is chronic once it has been present for 6 months or longer and/or originates in an unidentifiable area.

A nurse is preparing to conduct a general survey and assessment on a newly admitted client. Which of the following actions should the nurse plan to take? Have an informal conversation with the client before beginning the observation of the client. Complete all focused assessments prior to formulating thoughts regarding the client's general health status. Sit on the client's bedside with them to have close contact and maintain eye contact whenever possible. Engage in active listening with the client and allow the client to express concerns early in the assessment process.

Engage in active listening with the client and allow the client to express concerns early in the assessment process. Rationale: The nurse should engage in verbal communication that involves actively listening to the client. The nurse should keep interruptions to emergencies and provide their full attention to the client, to establish trust.

A nurse is documenting a client's vital signs in the medical record following a general survey. Which of the following entries should the nurse place in the record? Fever 101. Pulse rate is tachycardic. Oxygen saturation is 96% on oxygen 2 L/minute via nasal cannula. Blood pressure is 108/65.

Oxygen saturation 96% on oxygen 2L/minute via nasal cannula. Rationale: The nurse should record the percentage of the client's oxygen saturation and indicate whether the client is on room air or is receiving oxygen. If the client is on oxygen, the nurse should record the type of the device and the rate at which oxygen is being delivered.

A nurse is having difficulty obtaining a pulse oximetry reading from a client. The nurse should identify which of the following factors as possible interfering with a pulse oximetry reading? Hypertension Fever Recent scan with contrast dye Thin, brittle nails

Recent scan with contrast dye. Rationale: A nurse might have difficulty obtaining a pulse oximetry reading from a client who has recently undergone testing that involves an injection of a contrast dye into the circulatory system. The dye can alter the transmission of the LED light used by the pulse oximetry sensor.

A nurse is obtaining a client's pulse and notes a regular rhythm with a rate of 110/minute. The nurse should identify this as which of the following unexpected findings? Bradycardia Tachycardia Fasciculation Tachypnea

Tachycardia Rationale: A heart rate of greater than 100/min is considered tachycardia. The nurse should further assess the client for a potential cause, such as anxiety, fever, or pain.

A nurse is assessing a client's respirations and notes they are shallow and at a rate of 24/minute. The nurse should identify this as which of the following unexpected findings? Tachypnea Bradypnea Apnea Hyperventilation

Tachypnea Rationale: A client who has rapid, shallow breathing at a rate greater than 20/min is experiencing tachypnea. Tachypnea can be caused by fever, fear, or exercise, as well as by client conditions like alkalosis or pneumonia.

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. Which of the following terms should the nurse use to describe this involuntary movement? Fasciculation Spasticity Tic Myoclonus

Fasciculation Rationale: A client who has fasciculation will exhibit a continuous twitching motion of a muscle when the muscle is at rest.

When conducting a general survey of a client, the nurse should assess? Skin turgor Gait Pain Pupils Speech Temperature Respiratory rate Level of consciousness

Level of consciousness, speech, gait.

A nurse is providing teaching to a client who asks, "What are things that can affect my blood pressure?" Which of the following information should the nurse include as factories that affect blood pressure? Time of day. Obesity. Height. Diuretic medication. Smoking.

Time of day, obesity, diuretic medication, smoking.

A nurse is documenting information in a client's medical record. Which of the following information did the nurse collect during the general survey? Select all that apply. Past medical history. Height and weight. Use of assistive devices. Behavior and mood.

Use of assistive devices, height and weight, behavior and mood.