General Survey 3.0 Test

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

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 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 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

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 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 .

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

During the general survey , the nurse should identify the client's level of consciousness , speech , and gait should be observed . The purpose of the general survey is to obtain information regarding the client's general health . S

Fever 101

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

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 has been off and on for about a year now . I still have pain since the surgery last month , but it is getting better . The pain from my car accident 2 months ago will not go away The pain isn't always in the same place . "

" I have had this pain for 9 months " is correct . Pain is diagnosed as chronic once it has been present for 6 months or longer . " The pain isn't always in the same place is correct , Chronic pain may originate in an unidentifiable area . For example , fibromyalgia pain can be widespread affect different areas of the body at different times . " The pain from my car accident 2 months ago will not go away " is incorrect . The client's pain was attained from an injury that occurred 2 months ago and would be considered acute pain unless the pain lasted more than 6 months . Acute pain can be attributed to injury or illness , follows a predictable trajectory of healing , and does not last more than 6 months . " The pain has been off and on for about a year now " is correct . Pain is diagnosed as chronic once it has been present for 6 months or longer and may be intermittent " I still have pain since the surgery , but it is getting better " is incorrect . The client's pain is related to their surgery a month ago . Acute pain is related to an injury or illness and has a short duration , less than 6 months , and has a known pattern of healing.

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 ? ( You will find hot spots to select in the artwork below . Select only the hot spot that corresponds to your answer . )

25

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

Current medication list is incorrect . Although it is necessary for the client's current medication list to be collected and placed in the client's medical record , it is not part of the documentation collected during the general survey . Past medical history is incorrect . Although it is necessary for the client's past medical history to be collected and placed in the medical record , it is not part of the documentation collected during the general survey . Use of assistive devices is correct . The client's use of assistive devices is information that is collected during the general survey and should be documented in the client's medical record . Height and weight is correct . Measuring the client's height and weight is information that is collected during the general survey and should be documented in the client's medical record . Behavior and mood is correct . Observing the client's behavior and mood is information that is collected during the general survey and should be documented in the client's medical record .

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. 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 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 .

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

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 . 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 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

Time of day is correct . The nurse should explain to the client that blood pressure will increase during the day and begin to decrease in the late afternoon . Obesity is correct . Clients who are obese are at an increased risk for developing hypertension . Diuretic medication is correct . A client who takes diuretic medication will have a decreased blood pressure due to the reduction of resorption of sodium and water by the kidneys Height is incorrect . Height is not a factor that affects a client's blood pressure . Smoking is correct . Vasoconstriction of blood vessels occurs when a person smokes , causing an increase in blood pressure