The nurse is performing a general survey. Which action is a component of the general survey?

The nurse is performing a general survey. Which action is a component of the general survey?a.Observing the patient’s body stature and nutritional statusb.Interpreting the subjective information the patient has reportedc.Measuring the patient’s temperature, pulse, respirations, and blood pressured.Observing specific body systems while performing the physical assessment

ANS: AThe general survey is a study of the whole person that includes observing the patient’s physical appearance, body structure, mobility, and behavior.DIF:Cognitive Level: Understanding (Comprehension)REF: p. 127MSC: Client Needs: Safe and Effective Care Environment: Management of Care

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2.When measuring a patient’s weight, the nurse is aware of which of these guidelines?a.The patient is always weighed wearing only his or her undergarments.b.The type of scale does not matter, as long as the weights are similar from day to day.c.The patient may leave on his or her jacket and shoes as long as these are documented next to the weight.d.Attempts should be made to weigh the patient at approximately the same time of day, if a sequence of weights is necessary.

ANS: DA standardized balance scale is used to measure weight. The patient should remove his or her shoes and heavy outer clothing. If a sequence of repeated weights is necessary, then the nurse should attempt to weigh the patient at approximately the same time of day and with the same types of clothing worn each time.DIF:Cognitive Level: Understanding (Comprehension)REF: p. 129MSC: Client Needs: Safe and Effective Care Environment: Management of Care

3. A patient’s weekly blood pressure readings for 2 months have ranged
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between 124/84 mm Hg and 136/88 mm Hg, with an average reading of 126/86 mm Hg. The nurse knows that this blood pressure falls within which blood pressure category?a.Normal blood pressureb.Prehypertensionc.Stage 1 hypertensiond.Stage 2 hypertension

ANS: BAccording to the Seventh Report of the Joint National Committee (JNC 7) guidelines, prehypertension blood pressure readings are systolic readings of 120 to 139 mm Hg or diastolic readings of 50 to 89 mm Hg.DIF:Cognitive Level: Understanding (Comprehension)REF: p. 159MSC: Client Needs: Safe and Effective Care Environment: Management of Care

4.During an examination of a child, the nurse considers that physical growth is the best index of a child’s:a.General health.b.Genetic makeup.c.Nutritional status.d.Activity and exercise patterns.

ANS: APhysical growth is the best index of a child’s general health; recording the child’s height and weight helps determine normal growth patterns.DIF:Cognitive Level: Remembering (Knowledg……………………