ATI Health Assess 2.0 General Survey

A nurse is planning on obtaining an orthostatic blood pressure from a client who has syncope. In what order should the nurse take the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) 4. Take the client's blood pressure in a seated position. 2. Take the client's blood pressure in the supine position. 3. Keep the cuff in place and assist the client to a seated position. 1. Place the client in a supine position and allow them to rest. 5. Assist the client to stand and obtain their blood pressure.

1. Place the client in a supine position and allow them to rest is the first step. The nurse should place the client in the supine position and have them rest for at least 3 min. 2. Take the client's blood pressure in the supine position is the second step. The nurse should take the client's baseline BP and pulse reading while the client is supine. 3. 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. 4. Take the client's blood pressure in a seated position is the fourth step. The nurse should take the client's blood pressure and pulse while they are in a seated position. 5.Assist the client to stand and obtain their blood pressure is the fifth step. The nurse should assist the client to stand and take a standing blood pressure and pulse reading. Orthostatic hypotension is indicated by a drop in systolic pressure of greater than 20 mm Hg or in diastolic pressure of greater than 10 mm Hg after the client stands.

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.)

B is correct. The nurse should identify that 25 is the BMI of the client.

A nurse is completing an initial assessment checklist on an older adult client. The client is accompanied by their caregiver. For which of the following indicators should the nurse observe when assessing for potential maltreatment of the client? (Select all that apply.) Dirty clothing Unexplained physical injuries Oriented to person, place, and time Able to express coherent thoughts Malnourished appearance

Dirty clothing is correct. Dirty clothing on a client can be an indicator of neglect. Unexplained physical injuries is correct. Unexplained physical injuries can be an indication of physical abuse and require further assessment. Malnourished appearance is correct. A malnourished appearance might indicate that the client's caregiver is failing to provide basic necessities, such as food or water, and can be an indicator of neglect.

A nurse is preparing to obtain a client's height during a general survey. Which of the following actions should the nurse take? Measure the client's shoe heel height with a tape measure and deduct this amount. Have the client gently lift their chin and look toward the ceiling. Ensure the client's feet are in contact with the wall or measuring pole. Skip the height measurement if the client cannot stand.

Ensure the client's feet are in contact with the wall or measuring pole. Rationale: The nurse should ensure that the client's feet, shoulders, and buttocks are in direct contact with the measuring pole or against the wall if the stadiometer is a wall-mounted device.

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 Spasticity Tic Myoclonus

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

A nurse is documenting a client's vital signs in the medical record following a general survey. Which of the following entries should the nurse place in the record? Temperature 95° F, client is hypothermic Pulse rate indicates tachycardia Oxygen saturation 96% on oxygen 2 L/min via nasal cannula Blood pressure 108/65 mm Hg in left arm

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

A nurse is documenting information in a client's medical record during an initial assessment. Which of the following information should the nurse include in the documentation? (Select all that apply.) Current medication list Past medical history Use of assistive devices Height and weight Behavior and mood

Rationale: Use of assistive devices is correct. The client's use of assistive devices is part of the initial assessment and should be documented at this time. Height and weight is correct. Measuring the client's height and weight is part of the initial assessment and should be documented at this time. Behavior and mood is correct. Observing the client's behavior and mood is part of the initial assessment and should be documented at this time.

A nurse is having difficulty obtaining a pulse oximetry reading from a client. The nurse should identify that which of the following factors can interfere with obtaining a pulse oximetry reading? Hypertension Fever Recent scan with contrast dye Thin, brittle nails

Recent scan with contrast dye Rationale: A nurse might have difficulty obtaining a pulse oximetry reading from a client who has recently undergone testing that involved the injection of a contrast dye into the circulatory system. The dyes can alter the transmission of the LED light used by the pulse oximetry sensor.

A nurse is caring for a middle adult client who has stomatitis and is unable to hold an oral probe in their mouth. Which of the following alternative routes should the nurse use to obtain the most accurate core temperature of the client? Axillary Temporal Tympanic Rectal

Rectal Rationale: Although rectal temperatures are usually higher than oral temperatures, it is the most accurate method for obtaining a client's core temperature. Because obtaining a rectal temperature is invasive, it is not used often, but it is typically the route selected for a client who is not able to hold an oral probe in their mouth.

A nurse is obtaining a client's pulse and notes a regular rhythm with a rate of 110/min. The nurse should identify this as which of the following unexpected findings? Bradycardia Tachycardia Atrial fibrillation Pulse deficit

Tachycardia Rationale: A heart rate of greater than 100/min is considered tachycardia. The nurse should further assess the client for a potential cause, such as anxiety, fever, or pain.

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 Bradypnea Apnea Hyperventilation

Tachypnea Rationale: A client who has rapid, shallow breathing at a rate greater than 20 to 24/min is experiencing tachypnea. Tachypnea can be caused by fever, fear, or exercise, as well as client conditions like alkalosis or pneumonia.

A nurse is caring for a client who is reporting pain as 4 on a scale of 0 to 10. Upon further assessment, which of the following findings should the nurse identify as manifestations of chronic pain? (Select all that apply.) The client reports that the pain has been present for approximately 4 years. The client reports never feeling total relief from pain. The client's pain can be attributed to an acute injury or illness. The client reports that the pain is recurring and does not always originate in the same location. The client describes the pain as transient.

The client reports that the pain has been present for approximately 4 years is correct. Pain is diagnosed as chronic once it has been present for 6 months or longer. The client reports never feeling total relief from pain is correct. Persistent pain is defined as pain that lasts longer than 6 months and can reach a severe level. The pain continues to persist after the predicted trajectory of healing, and the level of pain does not correspond to physical findings. The client reports that the pain is recurring and does not always originate in the same location is correct. Recurrent pain that does not always originate in the same location can indicate abnormal processing of stimuli from pain receptors. As a result, chronic pain can originate from peripheral sites to the source of the pain.

A nurse is conducting a general survey on a client who is being admitted to a long-term care facility. The nurse is assessing the client's emotional state. Which of the following findings should the nurse record as a subjective, unexpected finding? The client is sitting in a relaxed posture. The client asks for a tissue and uses it to wipe away an occasional tear. The client tells the nurse that visits from their friends and family make them smile. The client reports they feel sad and lonely most of the time.

The client reports they feel sad and lonely most of the time. Rationale: The nurse should record this statement as a subjective, unexpected finding. It is subjective because it is something the client reported, and it is unexpected because a client who reports feeling sad and lonely most of the time should be evaluated for depression.

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 cause a decreased respiratory rate? The client has been a chronic smoker for 10 years. The client takes a narcotic pain medication for chronic pain. The client reports anxiety due to being in the hospital. The client has a history of anemia.

The client takes a narcotic pain medication for chronic pain. Rationale: 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 preparing to conduct an initial survey and assessment on a newly admitted client. Which of the following actions should the nurse plan to take? Have an informal conversation with the client before beginning observation of the client. Complete all focused assessments prior to formulating thoughts regarding the client's general health status. Engage in active listening with the client and allow the client to express concerns early in the assessment process. Sit on the client's bedside with them to have close contact and maintain eye contact whenever possible.

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, which will establish trust. Rationale: 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, which will establish trust.

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.) Time of day Obesity Diuretic medication Height Smoking

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. Smoking is correct. Vasoconstriction of blood vessels occurs when a person smokes, causing an increase in blood pressure.