General Survey 3.0 Test

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 .

" I have 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 "

A nurse is admitting a client who is 162.6 cm ( 64 in ) tall and weighs 68.2 kg ( 150 lb ) . Using the BMI table shown below , what should the nurse record as the client's BMI ?

25

A 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 a client and allow the client to expressed concerns early in the assessment process.

A nurse is preparing to obtain a client's height during a general survey. Which of the following actions 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 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

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 ? Select all that apply Diuretic medication Obesity Time of day Smoking Height

Obesity Time Of Day Diuretic Medication Smoking

A nurse is 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

A nurse is obtaining a clients pulse and notes a 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's respirations and notes 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 assesses 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 takes a narcotic pain medication for chronic pain .

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 . Behavior and mood . Past medical history Height and weight Use of assistive devices Current medication list

Height and weight Use of assistive devices behavior and mood

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

Oxygen saturation 96% on oxygen 2 L per minute via nasal cannula

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

Place the client in a supine position and allow them to rest is the first step. The nurse should place a client in the supine position and have them rest for at least three minutes. Take the clients blood pressure in the supine position is the second step. The nurse should take the clients baseline BP and pulse reading while the client is supine. Keep the cuff in place and assist the client to a seated position is the third step. The nurse should keep the cuff in place and assist the client to a seated position. Take the clients blood pressure in a seated position is the fourth step. The nurse should take the clients blood pressure and pulse while they are and seated position. Assist the client to stand and then obtain her blood pressure is the fifth step. The nurse should assess the client to stand and then take a standing blood pressure and pulse reading. Orthostatic hypertension is indicated by a drop in systolic pressure of greater than 20 mmHg or and diastolic pressure of greater than 10 mmHg after the client stands .

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 ?

Rectal

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 findings should the nurse record as an unexpected finding ?

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

When conducting a general survey of a client , the nurse should assess ___, ___, and ___

level of consciousness speech gait