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Exam 7: General Survey

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Question 21

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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.The nurse suspects that this variation in temperature is indicative of:

A) The client's temperature has been improperly assessed either in the morning or evening;the nurse can't be sure which.
B) The client is developing an infection.
C) The client is experiencing stress.
D) The client's temperature is demonstrating diurnal variations.

E) A) and B)
F) A) and C)

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Question 22

Multiple Choice

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The nurse is assessing a toddler when the child's mother tells the nurse 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 of the following would be the most appropriate response for the nurse?

A) "When our skin feels warm,it means our blood vessels are constricted."
B) "The only reliable indicator of body temperature is by feeling the forehead."
C) "Our skin temperature changes when our surroundings change temperature."
D) "The temperature of the skin is not related to what is happening inside our bodies."

E) B) and C)
F) A) and D)

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Question 23

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The nurse is admitting a client with a fractured hip.The client points to the painful hip and describes it as a constant throbbing.The nurse would include which of the following when continuing the pain assessment on this client?

During a physical assessment the client asks the nurse repeatedly,"Is everything ok?" The nurse believes this client is demonstrating:

A client presents to the primary care clinic and is disheveled in appearance,with stained,dirty clothing,body odor,and uncombed hair.Based on this observation,which of the following should the nurse assess during the history and physical exam?

The nurse in interviewing a client observes changing of position frequently,wringing hands,and laughing at inappropriate times.Which of the following would be appropriate for the nurse to include in the assessment based on this information?

The nurse is obtaining the height and weight of an older adult client.The client asks why the height is 1 inch less than last year.What is the best response by the nurse?

The nurse is entering the room to assess a newly admitted client.Which of the following best describes the purpose for a general survey? The general survey:

During the assessment of an adult client's blood pressure,the nurse notes the following on the sphygmomanometer: first faint tapping sounds at 136,swishing sounds at 120,clear tapping sounds at 108,muffled sounds at 98,and silence at 76.This nurse would document this client's blood pressure as_____________.

The nurse is doing a general survey on an infant for a well-child check.During the survey,the baby has a liquid stool.The mother becomes very angry and asks the nurse to change the diaper because she just can't "deal with the odor." This response is important to the nurse because:

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

The nursing staff is admitting a client diagnosed with diabetic ketoacidosis (DKA) .The LPN asks the RN if the pulse oximeter needs to be placed on the client.What is the nurse's best response to the LPN?

The nurse is assessing a client's left femoral pulse.Identify the area on the diagram below where the nurse would locate this pulse.