Question 1

During an interview with an older adult client, the nurse notes the client is confused as to day and time. The nurse documents this finding as an indicator of which item?

Accepted Answer

Confusion about the day and time is a sign of impaired orientation, which is an important aspect of cognitive functioning.

Question 2

The nurse is obtaining vital signs for a newborn client. Which route and sequence will the nurse use to obtain vital signs on this client?

Accepted Answer

For a newborn client, the recommended sequence to obtain vital signs is respirations, apical pulse rate, and axillary (or skin) temperature. This sequence provides the most accurate readings and is least intrusive for the newborn. Blood pressure is not routinely measured in newborns unless there is a medical indication. Rectal temperature is not recommended due to the risk of infection and potential discomfort for the newborn. Oral temperature is also not recommended in newborns as they are not able to keep the thermometer in their mouth for an adequate amount of time.

Question 3

The nurse is assessing an older adult client with arteriosclerosis and obtains a blood pressure reading of 172/98 mmHg. Which factors may be applicable in this situation?

Accepted Answer

Arteriosclerosis leads to decreased blood vessel compliance, making them stiffer and less able to expand, which can contribute to increased blood pressure. Age also contributes to decreased blood vessel elasticity, further exacerbating the problem of high blood pressure in older adults.

Question 4

A young adult client presents to the clinic complaining of a sore throat, swollen glands, and fever following oral surgery for extraction of impacted wisdom teeth. In order to complete the initial assessment of this client, the nurse needs to obtain the client's temperature. Which method should the nurse choose for this assessment?

Accepted Answer

Since the client just underwent oral surgery, using the oral method may cause discomfort and potential bleeding. The axillary method may not provide an accurate reading due to sweating and the rectal method may be invasive and uncomfortable. The tympanic method can provide an accurate reading and does not interfere with the oral surgical site.

Question 5

The nurse educator is preparing an in-service on pain management for the staff. One of the staff nurses asks, "What is the most important part of a pain assessment?" Which response by the nurse educator is the most appropriate?

Accepted Answer

The response to pain is unique and based on numerous factors, which need to be assessed. This includes factors such as the location and intensity of the pain, the client's perception of the pain, the duration of the pain, and any factors that may exacerbate or alleviate the pain. A thorough pain assessment is critical to developing an effective pain management plan.

Question 6

The nurse is obtaining the initial vital signs on a client in the emergency department (ED) with seizure activity of unknown etiology. Which method is most appropriate for the nurse to use when assessing the client's temperature?

Accepted Answer

Rectal temperature is the most accurate method of assessing temperature in a client with seizure activity of unknown etiology.

Question 7

The nurse is caring for a client diagnosed with breast cancer who underwent a left-sided mastectomy two days prior. The nurse has delegated vital signs on this client to the unlicensed assistive personnel (UAP). What specific instructions should the nurse provide to the (UAP) in delegating this task?

Accepted Answer

The nurse should instruct the UAP to take the blood pressure on the right arm, as the left arm may be affected by the mastectomy, and taking the blood pressure on the left arm may cause pain, discomfort, or alter the blood pressure readings. This ensures the safety and comfort of the client.

Question 8

The nurse needs to take a blood pressure on a very thin client, and the only cuff available is a standard size. Which type of blood pressure reading does the nurse expect?

Accepted Answer

The answer of The nurse needs to take a blood...

Question 9

An older adult client says to the nurse, "I'm gaining weight around my middle and my legs look like chicken legs." Which response by the nurse is the most appropriate?

Accepted Answer

Option A provides accurate and reassuring information about body changes that are common in aging. It also normalizes the experience, which can help alleviate the client's concerns. Option B is a closed-ended question that can make the client feel judged or uncomfortable. Option C is inappropriate because it exaggerates the seriousness of the client's concerns without further assessment or evidence. Option D assumes that the client's weight gain is related to their diet, which may not be accurate.

Question 10

The nurse is assessing a 15-month-old toddler client. Which site is the most appropriate for the nurse to use when assessing the pulse?

Accepted Answer

The apical site is the most appropriate for assessing the pulse in a 15-month-old toddler because it provides the most accurate assessment of heart rate in infants and young children.

Question 11

The nurse is assessing an adult client. Which observations should the nurse include when documenting the general survey of this client?

Accepted Answer

The general survey includes overall observations of the client's appearance and behavior, which includes noting the client's age, body build, grooming, posture, and ability to move around. Therefore, options B and C are the most appropriate choices for documenting the general survey. Options A, D, and E are specific observations and do not relate to the general appearance and behavior of the client.

Question 12

The night nurse is reviewing the vital signs of a client in an extended care facility. The nurse notes the client's oral temperature at 6 a.m. was 98.0°F, but that evening, the client's oral temperature was 99.2°F. What is this variation indicative of?

Accepted Answer

The variation in temperature between morning and evening is likely due to diurnal variations, which are normal fluctuations in body temperature throughout the day. It is important to note that a temperature of 99.2°F is still within the normal range and may not indicate an infection or other health concern.

Question 13

The nurse educator is observing the student nurse take a blood pressure on an older adult client. When is it appropriate for the nurse educator to intervene during this assessment?

Accepted Answer

The answer of The nurse educator is observing the student...

Question 14

During the evening assessment of a febrile client admitted to the nursing unit with abdominal pain, the nurse assesses a lower than normal blood pressure and a rapid pulse. What is the most likely cause of these findings?

Accepted Answer

A lower than normal blood pressure and a rapid pulse are common signs of sepsis, which is often caused by a bacterial infection in the abdominal area, such as appendicitis or peritonitis. Anxiety, a medication reaction, and diurnal variation are less likely to cause these symptoms.

Question 15

The nurse is assessing a client's left brachial pulse. Which area will the nurse palpate to assess this pulse?

Accepted Answer

The answer of The nurse is assessing a client's left...

Question 16

The nurse is entering the room to assess a newly admitted client. Which best describes the purpose for a general survey that is conducted prior to beginning the physical assessment?

Accepted Answer

The purpose of a general survey is to gather information that will guide the physical assessment, such as the client's overall appearance, level of consciousness, and vital signs. It can also help identify any potential safety concerns or areas for further assessment.

Question 17

A young adult client notes height as "5 feet 11 inches" and weight as "200 lbs." Upon assessment, the client is found to be 5 feet 9 inches tall with a weight of 225 lbs. Which is the most likely cause of this discrepancy?

Accepted Answer

The most likely cause of this discrepancy is that the client has an image of self that is inconsistent with actual findings. This is a common phenomenon known as "body image distortion" where an individual may have a distorted perception of their own body size or shape. The client may believe they weigh less and are taller than they actually are, which could lead to discrepancies in reporting. It is less likely that the client did not want to tell the truth or is trying to hide a chronic illness as these would require additional evidence or reasons to support. The client not having a scale at home may have contributed to the discrepancy, but body image distortion is a more likely explanation.

Question 18

The nurse is assessing a toddler when the child's mother states that the child has had a fever for the past two days. When the nurse asks the mother what the temperature has been, the mother replies that she hasn't actually taken it but the child's skin has felt very warm. Which response by the nurse is appropriate in this situation?

Accepted Answer

The nurse's response that skin temperature changes with changes in surrounding temperature is correct because it acknowledges that external factors can influence how warm or cool the skin feels, without confirming fever or diagnosing based on touch alone. This response educates the mother on why skin warmth alone is not a reliable indicator of fever.

Question 19

The nurse is preparing to assess a client's mental status within the general survey. Which data should the nurse use to assess this status?

Accepted Answer

Asking the client to describe elements of his health history helps assess cognitive function, memory, and thought processes, which are key components of mental status.

Question 20

The nurse observes the client walking into the room and climbing up on the exam table. The nurse notes this activity to obtain data related to which item?

Accepted Answer

The nurse observing the client walking and climbing up on the exam table is obtaining data related to the client's mobility status.

Quiz 10: General Survey