GENERAL SURVEY Flashcards
a nurse is assessing a client who is admitted with abdominal pain. the client reports that the pain is “in the stomach and is a crampy, dull ache.” which type of pain should the nurse identify this client is experiencing?
visceral
a nurse is reviewing the vital signs for a client who was admitted with shortness of breath. the nurse notes the client’s respiratory rate is 24/min. the nurse should use which of the following terms when documenting this finding?
tachypnea
A nurse is measuring the respiratory rate of a client who has an irregular breathing pattern. For how many seconds should the nurse count the client’s respiration?
1 full minute
A nurse is measuring the oxygen saturation of a client who has cyanosis of the extremities. using a pulse oximeter, where does the nurse place the sensor probe?
> forehead
forefinger
bridge of nose
earlobe
which of the following is considered an unexpected finding for a 40-year-old client’s pulse?
stronger radial pulse on left compared to right
a nurse is taking a rectal temperature on a client. which of the following actions does the nurse perform?
> lubricates the probe cover
>inserts the probe into rectum 1 to 1.5 in
A nurse is performing an initial survey on a client and calculates a BMI of 31 kg/m^2. The nurse classifies this client in which of the following wight ranges
obese
A nurse is calculating the BMI for a client who weighs 150 lb and is 5ft 4 in… what is the BMI
25.7
A nurse is assessing a client’s behavior during the initial survey. Which of the following does the nurse include in this assessment.
> client’s clothing
>client’s speech
A nurse is performing an initial assessment on a client’s skin. Which of the following observations will require further assessment of the client’s circulation?
Cyanosis is noted on fingers
you are documenting the client’s pain in a narrative note. which of the following statements would be most appropriate to include in the medical record?
“my pain is a 7”
You are documenting the client’s level of orientation in a narrative note. Which of the following statements would be most appropriate to include in the medical record?
The client is oriented to person and situation but unable to correctly identify the time
which sample charting would be most appropriate to include in the medical record?
Mr. Dobbs is cooperative and follows commands. He is oriented to person, and situation but is unable to correctly identify the current year. The client states “My pain is a 7” and identifies his stomach as the site of his pain. Client is observed grimacing and holding his hand over his stomach. His skin is intact with exception of noticeable dry patches on scalp and a scar on the right knee. He is able to walk without assistance
A nurse is performing an initial assessment on a client’s skin. Which of the following observations will require further assessment of the client’s circulation?
A: Skin is warm to touch
B: Skin is dry
C: Freckles are noted on face
D: Cyanosis is noted on fingers
D: Cyanosis is noted on fingers
Rationale: Cyanosis, or bluish skin color, indicates poor blood flow. The nurse will need to check capillary refill and radial pulses.
A nurse is assessing a client’s behavior during the initial survey. Which of the following does the nurse include in this assessment? Select all that apply.
A: Client's level of education B: Client's clothing C: Client's speech D: Client's occupation E: Client's hobbies
B: Client’s clothing
Rationale: The type of clothing a client is wearing can offer information to the nurse about client behavior. For example, a client wearing dirty, unkempt clothing may have a lack of desire to look neat due to depression, or an inability to care for self due to financial or physical concerns
C: Client’s speech
Rationale: The client’s speech is included in the assessment of client behavior. For example, a client who has difficulty expressing an idea could have aphasia
A nurse is performing an initial survey on a client and calculates a BMI of 31 kg/m^2. The nurse classifies this client in which of the following weight ranges?
A: Underweight
B: Normal weight
C: Overweight
D: Obese
D: Obese
Rationale: A client with a BMI greater than 30 kg/m^2 is considered obese
A nurse is taking a rectal temperature on a client. Which of the following actions does the nurse perform? Select all that apply.
A: Selects the blue probe.
B: Lubricates the probe cover
C: Asks the client to lie in a prone position
D: Inserts the probe into the rectum 1 to 1.5in
E: Cleans probe with warm soapy water after use
B: Lubricates the probe cover
Rationale: The cover is lubricated for comfort and prevention of injury
D: Inserts the probe into the rectum 1 to 1.5in
Rationale: The nurse does not want to insert further than 1.5in due to risk of injury
Which of the following is considered an unexpected finding for a 40-year-old client’s pulse?
A: Brisk pulse strength of +2
B: Equal time space between each pulsation
C: Pulse rate of 95/min
D: Stronger radial pulse on left compared to right
D: Stronger radial pulse on left compared to right
Rationale: An equal bilateral pulse is considered an expected finding. This assessment may indicate blood flow or malposition of the right radial artery
A nurse is measuring the oxygen saturation of a client who has cyanosis of the extremities. Using a pulse oximeter, where does the nurse place the sensor probe? Select all that apply.
A: Forefinger B: Thumb C: Forehead D: Bridge of nose E: Earlobe F: Great toe
C: Forehead
D: Bridge of nose
E: Earlobe
Rationale: When a client has cyanosis of the extremities, it is best to select an area with good circulation.
A nurse is measuring the respiratory rate of a client who has an irregular breathing pattern. For how many seconds should the nurse count the client’s respirations?
1 min (or 60 seconds)
Rationale:
The nurse should count respirations of a client who has an irregular breathing pattern for 1 full minute. This ensures that the calculated rate is accurate.
A nurse is reviewing the vital signs for a client who was admitted with shortness of breath. The nurse notes the client’s respiratory rate is 24/min. The nurse should use which of the following terms when documenting this finding?
A: Hypoventilation B: Apnea C: Tachypnea D: Cheyne-stokes respirations E: Labored
C: Tachypnea
Rationale: Tachypnea is the term for a respiratory rate which is above the expected range of 12 to 20 breaths per minute for an adult
A nurse is assessing a client who is admitted with abdominal pain. The client reports that the pain is "in the stomach and is a crampy, dull ache." Which type of pain should the nurse identify this client is experiencing? A: Neuropathic B: Somatic C: Visceral D: Referred
C: Visceral
Rationale: Visceral is pain related to large internal organs
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 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
A client who has fasciculation will exhibit a continuous twitching motion of a muscle when the muscle is at rest.
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
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 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.
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 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
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 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
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 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 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.)
- Take the client’s blood pressure in a seated position.
- Take the client’s blood pressure in the supine position.
- Keep the cuff in place and assist the client to a seated position.
- Place the client in a supine position and allow them to rest.
- Assist the client to stand and obtain their blood pressure.
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.
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.
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 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.
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 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.
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 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
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 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 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.
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.) 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.
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
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
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.
Assessment
gather data from the client through interview, PE, and observation to make judgements
Planning
use problem-solving and decision making skills to prioritize outcomes and goals, and develop interventions to meet those goals
Implentation
carry out the interventions that have been established, use clinical judgement to monitor the client’s progress towards achieving their goals
Analysis
use clinical judgement to evaluate data collected to formulate the client’s problems, including actual and potential problems
evaluation
assess the effectiveness and achievability of the goals and the need for interventions to be adjusted
What are some parts of critical thinking? (5)
contextual awareness, analyzing assumptions, exploring alternatives, using credible sources, reflecting and deciding
what is contextual awareness?
understanding the status of the client and the events that have led to their interaction with the healthcare team
what does analyzing assumptions involve?
involves the nurse evaluating the client’s clinical situation and the use or modification of standard approaches to meet the health needs and concerns of the client
Example of analyzing assumption w someone who has an open fraction to a lower extremity. what would be more beneficial?
nurse should evaluate whether it would be more beneficial to perform a focused assessment of the injured area or to engage in a standard head to toe approach when performing the health assessment
how would you explore alternatives in nursing?
this includes the use of holistic approaches for treating the whole person
what factors should be considered when providing care for a patient?
a culmination of the individual’s physical health, lifestyle choices, culture, living environments, and life experiences
what is considered using credible sources when providing care?
using institution standards, state standards, and multiply scholarly sources to determine best practices
how does reflecting and deciding the best care for the patient essential?
nurses should do self reflecting, then reflect on the client goals and decide on interventions with client input
what should the nurse be aware of?
appropriate methods of communication among team members
what kind of care is a priority?
evidence based
what is not part of critical thinking for PNs
analyzing assumptions
what are the ethical practices? 5
nonmaleficence, beneficence, autonomy, justice, confidentiality
what is first and foremost in healthcare?
nonmaleficence
what does nonmaleficence mean?
to do no harm
what does beneficence mean?
to act to promote the good of the client
what is the ultimate goal for the client
a return to health and homeostasis
what does autonomy mean?
the client’s right to make decisions. they may also refuse treatment if they desire
