Chapter 3 Preforming a general survery quiz Skills W3

The nurse is performing a general survey on a client who is being admitted to the medical unit with abdominal pain. Which components would the nurse assess during the general survey? Select all that apply.

Assess the client's vital signs Rational: The general survey is a precursor to any in-depth focused physical assessment. The general survey provides initial information about the client's overall demeanor, orientation, vital signs, appearance, gait, and behavior and can indicate the need for further targeted assessments. Evaluating the client's bowel pattern and palpating the entire abdomen would fall under the targeted abdominal assessment.

The nurse is asking admission interview questions, and the client has explained the reason for seeking care. Which is the most appropriate way to document the response?

Client states, "I feel winded all of the time, and yesterday I started spitting up a lot of phlegm. Rationale:The client's reason for seeking care should always be stated in the client's own words.

The nurse is preparing to obtain biographical data from a client before initiating a health assessment. Which biographical data should the nurse plan to collect? Select all that apply.

Date of birth, Name, Occupation, Gender Rationale:Biographical data include name, address, billing and insurance information, gender, age and birthdate, marital status, race, ethnicity, occupation, religious preference, advance directives/living will, health care financing, and health care provider. Data about sexual orientation would be collected as part of the psychosocial and lifestyle factors section of the assessment, if appropriate, and not in the general biographical section. Data regarding political party affiliation are not typically collected.

Which senses are used when the nurse performs the inspection phase of assessment? Select all that apply.

Hearing, Sight, Smell Sight, smell, and hearing are used for inspection. Touch is used during the palpation phase. Taste is not used for client assessment.

The nurse is about to conduct a general survey on a client being admitted to the medical-surgical unit. What should the nurse do first?

Identify the client by two methods. Rationale:The general survey is the first component of the health assessment, beginning at the moment contact is made with the client. The first step is to identify the client, followed by observing general appearance, orientation, behavior, height, weight, and vital signs.

The nurse is beginning a general survey on a client who is being admitted to the hospital for abdominal pain. After identifying the client, which components would the nurse include in the general survey? Select all that apply.

Is the client's color appropriate for ethnicity?, Does the person's body structure match the stated age?, Are there any tubes, lines, or drains?, Does the client appear to be alert? Rationale:After identifying the client, a general survey is completed by observing general appearance including whether the client is wearing oxygen, has an IV or other lines, the demeanor and behavior, body structure, BMI, and vital signs. This is then followed by a brief, generalized assessment from head to toe with the addition of in depth targeted assessments as needed, based on the client.

When performing a general survey assessment, how would the nurse assess the client's orientation? Select all that apply.

Query about today's date and season., Question where the client is now., Request the client states his or her name. Rationale:When assessing for the client's orientation, the nurse should assess the client for person, place, time, and situation. Asking about allergies and medications are not included in orientation.

Which senses are used when the nurse performs the inspection phase of assessment? Select all that apply.

Sight, smell, and hearing are used for inspection. Touch is used during the palpation phase. Taste is not used for client assessment. Rationale:The general survey should include vital signs, which require a sphygmomanometer, as well as a height, weight, and BMI, which require a standing scale and a tape measure. A glucometer is not necessary to perform a general survey, it but could be used later during the physical assessment. A Doppler is not indicated unless the nurse was unable to palpate a pulse in a normal manner.