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The nurse records the following general survey of a patient: 'The patient is a 68-year-old Indigenous male accompanied by his wife and two daughters. Alert and oriented. Does not make eye contact with the nurse and responds slowly, but appropriately, to questions. No apparent disabilities or distinguishing features.' Which of the following areas does the nurse need to assess to complete the general survey?
- A. Body movements
- B. Intake and output
- C. Reasons for contact with the health care system
- D. Comments of family members about his condition
Correct Answer: A
Rationale: To complete a general survey, the nurse needs to assess the patient's body movements. Intake and output, reasons for contact with the health care system, and comments of family members about the patient's condition are not part of the general survey.
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The nurse records the following general survey of a patient: 'The patient is a 78-year-old Asian female accompanied by her two daughters. Alert and oriented. Does not make eye contact with the nurse and responds appropriately to questions. No apparent disabilities or distinguishing features.' Which of the following information should be added to this general survey documentation?
- A. Nutritional status
- B. Intake and output
- C. Reasons for contact with the health care system
- D. Comments of family members about his condition
Correct Answer: A
Rationale: The general survey also describes the patient's general nutritional status. The other information will be obtained when doing the complete nursing history and examination but is not obtained through the initial scanning of a patient.
An older-adult patient who is having difficulty breathing is admitted to the hospital. Which of the following approaches is the best for the nurse to use to obtain a complete health history?
- A. Obtain subjective data about the patient from family members.
- B. Omit subjective data collection and obtain the physical examination.
- C. Use the health care provider's medical history to obtain subjective data.
- D. Schedule several short sessions with the patient to gather subjective data.
Correct Answer: D
Rationale: In the case of an older-adult patient with a low energy level, several short sessions may have to be scheduled. Allowing time for the patient to volunteer information about particular areas of concern enables the nurse to work with the patient to identify existing and potential health problems. In an emergency situation, the nurse may need to ask only the most pertinent questions for a specific problem and obtain more information later. A complete health history will include subjective information that is not available in the health care provider's medical history. Family members may be able to provide some subjective data, but only the patient will be able to give subjective information about the shortness of breath. Since the subjective data about the patient's respiratory status will be essential, obtaining the physical examination alone will not provide sufficient information.
During the health history interview, a patient tells the nurse about periodic fainting spells. Which question by the nurse will be most helpful in determining the setting in which the fainting spells occur?
- A. How frequently do you have the fainting spells?
- B. Where are you when you have the fainting spells?
- C. Do the spells tend to occur at any special time of day?
- D. Do you have any other symptoms along with the spells?
Correct Answer: B
Rationale: Information about the setting is obtained by asking where the patient was and what the patient was doing when the symptom occurred. The other questions from the nurse are appropriate for obtaining information about chronology, frequency, and associated clinical manifestations.
When assessing the circulation to the lower leg of a patient who has had knee surgery, which action should the nurse take first?
- A. Feel for the temperature of the foot.
- B. Visually inspect the colour of the foot.
- C. Check the patient's pedal pulses using the fingertips.
- D. Compress the nail beds to determine capillary refill time.
Correct Answer: B
Rationale: Inspection is the first of the major techniques used in the physical examination. Palpation and auscultation are used later in the examination.
The nurse is completing a neurological assessment on an adult patient. Which of the following assessments should the nurse include when assessing the patient's coordination?
- A. Toe walk
- B. Finger to nose
- C. Drift
- D. Romberg
- E. Heel to opposite shin
Correct Answer: B,D,E
Rationale: A neurological assessment is completed to observe motor status by assessing gait, toe and heel walk, and drift, whereas when assessing coordination, the nurse observes finger to nose, Romberg sign, and heel to opposite shin.