General survey 3.0

When conducting a general survey, the client the nurse should assess

Level of consciousness, speech, and gate

Are nurses having difficulty obtaining a pulse oximetry reading from a client. The nurse should identify which of the following factors, as possibly interfering with obtaining a pulse oximetry reading.

Recent scan with contrast dye

The nurses obtaining a clients pulse in notes regular rhythm with a rate of 110/min. The nurse should identify this as which of the following unexpected findings.

Tachycardia

A nurse is assessing a client, respirations and note they are shallow and at a rate of 24/min. The nurse should identify this as which of the following unexpected findings.

Tachypnea

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

1. Place the client in a supine position and allow them to rest 2. take the clients blood pressure in the supine position 3. keep the cup in place and assess the client to a seated position 4. Take the current blood pressure and in a seated position 5. Assist the client stand and then obtain their blood pressure

The nurse is preparing to conduct a general survey and assessment on a newly admitted client. Which of the following action should the nurse plan to take

Engage in active, listening with the client and allow the client to expressed concerns early in the assessment process

A nurse is preparing to obtain a client site during a general survey. Which of the following action should the nurse take?

Ensure the clients feet are in contact with the wall or measuring pole

A nurse is conducting a general survey on a client in notes, a continuous twitching movement of a muscle in the clients left arm. Which of the following terms should the nurse use to describe this involuntary movement

Fasciculation

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.

I have had this pain for nine months, the pain isn't always in the same place, the pain has been of and on for about a year now

A nurse is documenting the clients vital signs in the medical records, following a general survey. Which of the following entry should the nurse place in the record?

Oxygen saturation 96% on oxygen 2 L/min via nasal cannula

A nurse is caring for an adult client who is comatose. Which of the following route should the nurse use to take the most accurate core body temperature of the client

Rectal

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 factors that affect blood pressure

Smoking, obesity, time of day, diuretic medicine

While conducting a general survey on a client who is being admitted to a long-term care facility, a nurse is assessing the clients emotional state. Which of the following findings should the nurse record as an unexpected finding.

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

A nurse assesses a client, 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 clients respiratory rate.

The client takes a narcotic pain medication for chronic pain

A nurse is documenting information in a clients medical record. Which of the following information did the nurse click during the general survey

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