general survey

Which of these statements is an open-ended question?

"How are you feeling?"

The nursing student is caring for a client who has difficulty speaking English. Which statement made by the nursing student would cause communication problems with the client?

"I will involve the client's family members as interpreters."

Which statements about culturally congruent care by the student nurse are correct? Select all that apply

"It is the main goal of transcultural nursing." "It depends on the patterns and needs of an individual." "It is provided through cultural competence."

Which statement describes the step followed to provide competent care for vulnerable populations?

"Understand the clients' cultural beliefs, values, and practices to determine their specific needs and interventions.

stage 1 hypertension

130-139/80-89

stage 2 hypertension

140/90

In which area would the nurse place the stethoscope when taking an apical pulse?

5th intercostal space between the midclavicular line

pulse rate

60-100bpm

how many seconds for respirations

60s 30x2

Which client's need would be considered priority?

A) A client with dysphagia who is choking while eating B) A client who needs discharge teaching about medications C) A client who needs a dressing change of the surgical wound D) A client who has a knowledge deficit regarding the use of an insulin pen A

The nurse is assessing a client who was admitted with a head injury. The nurse finds that the client is unable to understand written or verbal speech. Which condition would the nurse suspect?

Aphasia

Which step in the nursing process involves the nurse interviewing a client about a current health problem and taking the client's vital signs?

Assessment

Which statement regarding an interpreter is correct

Interpreting not only the language but also the culture is important.

Auscultation

Listening with a stethoscope to sounds within the body

The nurse assesses the vital signs of a 50-year-old female client and documents the results. Which are considered within normal range for this client? Select all that apply

Oral temperature of 98.2°F (36.8°C) Apical pulse of 88 beats/min and regular Blood pressure of 116/78 mm Hg while in a sitting position

The nurse identifies which weight category as reflective of a client's body mass index (BMI) of 25.5 kg/m ?

Overweight

The nurse is obtaining a health history from the newly admitted client who has chronic pain in the right knee. Which would the nurse include in the pain assessment? Select all that apply.

Pain history, including location, intensity, and quality of pain Pain pattern, including precipitating and alleviating factors

The nurse is caring for an older adult client with dementia. Which client need would the nurse prioritize while providing care?

Safety

A client says, "Do not cut the thread on my wrist before sending me for surgery because the thread is a blessing from God." Which internal variable influences the client's health belief in this scenario?

Spiritual factors

factors that can affect blood pressure

Stress, age, weight, rest, caffeine, medications, race, diabetes, exercise, kidney disease, time of day

A nursing student is conducting an assessment of a client who does not speak English. No interpreter is available. Which action by the student nurse is incorrect?

Using medical terminology

The nurse is questioning a client who reports pain. Which questions asked by the nurse are correct? Select all that apply.

Where does it hurt?" "What makes the pain worse?" "How long have you noticed it?" "How severe is your pain on a scale of 0 to 10?"

health literacy

a person's capacity to learn about and understand basic health information and services, and to use these resources to promote one's health and wellness

halitosis

bad breath

included in health literacy

basic reading skills ability to follow verbal instructions

components of functional health assessment

determines the client's ability to care for themselves

review of symptoms

head eyes ears nose mouth neck

during general survey

height and weight behavior and mood use of assistance

aphasia

inability to speak

Spactisity

increased muscle tone

skin turgor assessment

inferior to collar bone

during general surevey the nurse should identify

level of consciousness speech gait

pallor is best observed

lips muc membranes nail beds

gait

manner of walking

neurophatic pain

nerves

Which client assessment finding would the nurse document as subjective data?

pain rating

referred pain

pain that is felt in a location other than where the pain originates

somatic

pertaining to the body

visceral

pertaining to the internal organs

steps of taking blood pressure

place in supine take in supine assist in seated position take seated assist up and take standing

Which methods qualify as alternative therapies for pain? Select all that apply.

prayer hypnosis aromatherapy guided imagery

Which kind of health care service involves vaccinating people against diseases?

preventative care

Fasciculation

rapid continuous twitching of resting muscle without movement of limb

myoclonus

rapid sudden jerk of a muscle

Most accurate core temp.

rectal

tic

repetitive twitching of a muscle group at inappropriate times

rigidity

resistance to passive movement

tremors

rhythmic, quivering, purposeless skeletal muscle movements

Dysarthria

slurred speech

percussion

tapping on a surface to determine the difference in the density of the underlying structure

inspection

the act of examining or reviewing

palpation

to examine by touch

stupor

unconsciousness but responds to pain

The nurse is assessing a client who underwent abdominal surgery 10 days ago. The client complains of pain in the abdomen. Which type of pain would the client experience?

visceral pain