Back to Product

Test Bank + Answers Ch8 General Survey and Physical Exam

Health & Physical Assessment in Nursing, 4e (Fenske/Watkins/Saunders/D'Amico/Barbarito)

Chapter 8 General Survey and Physical Exam: Objective Data

The nurse is preparing to conduct a general survey. Which should the nurse recognize is the purpose of performing the general survey prior to the physical assessment?

1. Allows for vital signs prior to starting exam.

2. Provides an opportunity for the client to relax before the exam.

3. Yields information to guide the physical assessment.

4. Provides the information necessary for the diagnosis.

Page Ref: 97

Cognitive Level: Understanding

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 8.1: Identify the components of the general survey.

MNL Learning Outcome: 8.1: Recognize the components of the general survey, including the functional assessment.

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?

1. Mobility.

2. Balance.

3. Activity tolerance.

4. Strength of upper and lower extremities.

Page Ref: 97

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Learning Outcome: 8.1: Identify the components of the general survey.

MNL Learning Outcome: 8.1: Recognize the components of the general survey, including the functional assessment.

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

1. Blood pressure 112/68, pulse 68, 98.6°F, and respiratory rate 16.

2. Thin, well-nourished male client appears younger than stated age.

3. Client ambulatory without difficulty.

4. Abdomen flat, nondistended, bowel sounds present, and nontender on palpation.

5. Pain rating of 3 on a 0 to 10 scale.

Page Ref: 97

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Learning Outcome: 8.1: Identify the components of the general survey.

MNL Learning Outcome: 8.1: Recognize the components of the general survey, including the functional assessment.

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?

1. Observation of the client ambulating.

2. Asking the client to describe elements of his health history.

3. Observation of the client's clothing selections.

4. Observation of eye contact during the examination.

Page Ref: 97

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Learning Outcome: 8.1: Identify the components of the general survey.

MNL Learning Outcome: 8.1: Recognize the components of the general survey, including the functional assessment.

A client is unable to identify the correct date and time during a health interview. Which indicator should the nurse document the finding as?

1. Affect and mood.

2. Orientation.

3. Cooperation.

4. Level of anxiety.

Page Ref: 97

Cognitive Level: Applying

Client Need & Sub: Psychosocial Integrity; Sensory/Perceptual Alterations

Learning Outcome: 8.4: Interpret nurse-patient encounter findings accurately.

MNL Learning Outcome: 8.1: Recognize the components of the general survey, including the functional assessment.

The nurse is preparing to obtain initial vital signs on a client with seizure activity of unknown etiology. Which method should the nurse use to obtain the temperature?

1. Axillary.

2. Oral.

3. Rectal.

4. Tympanic.

Page Ref: 102

Cognitive Level: Applying

Client Need & Sub: Safe and Effective Care Environment; Accident/Error/Injury Prevention

Learning Outcome: 8.3: Determine which techniques will ensure accurate measurement of vital signs.

MNL Learning Outcome: 8.3: Examine the factors that influence the measured results of vital signs.

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

1. Wrist.

2. Behind the knee.

3. Cubital fossa.

4. Neck.

Page Ref: 104

Cognitive Level: Understanding

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Learning Outcome: 8.3: Determine which techniques will ensure accurate measurement of vital signs.

MNL Learning Outcome: 8.4: Apply the principles of assessing vital signs in patient care.

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

1. Rectal temperature, respirations, and pulse rate.

2. Respirations, pulse rate, blood pressure, and rectal temperature.

3. Respirations, apical pulse rate, and axillary temperature.

4. Oral temperature, respirations, pulse rate, and blood pressure.

Page Ref: 108

Cognitive Level: Understanding

Client Need & Sub: Health Promotion and Maintenance; Ante/Intra/Postpartum and Newborn Care

Learning Outcome: 8.3: Determine which techniques will ensure accurate measurement of vital signs.

MNL Learning Outcome: 8.4: Apply the principles of assessing vital signs in patient care.

The nurse is preparing to assess the temperature of a child post oral surgery suspected of having an infection. Which route should the nurse use?

1. Oral.

2. Tympanic.

3. Rectal.

4. Axillary.

Page Ref: 102

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Learning Outcome: 8.3: Determine which techniques will ensure accurate measurement of vital signs.

MNL Learning Outcome: 8.4: Apply the principles of assessing vital signs in patient care.

The nurse is assessing an adult client's pulse. Which method should the nurse initially use?

1. Monitoring for a full 2 minutes.

2. Monitoring for 1 complete minute.

3. Monitoring for 30 seconds and multiply by 2.

4. Monitoring for 15 seconds and multiply by 4.

Page Ref: 104

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment

Learning Outcome: 8.3: Determine which techniques will ensure accurate measurement of vital signs.

MNL Learning Outcome: 8.4: Apply the principles of assessing vital signs in patient care.

The new nurse asks the educator, "What is the most important part of a pain assessment?" Which response should the nurse educator provide?

1. "Pain is only partially subjective and primarily a physiologic experience, so vital signs are the most important assessment."

2. "A client's response to pain is always based on the underlying cause, so the client's admitting diagnosis is important."

3. "Vital signs are not reliable indicators of acute pain because only some clients are able to elicit a change in blood pressure or pulse rate."

4. "The response to pain is unique and based on numerous factors, which need to be assessed."

Page Ref: 101

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity; Basic Care and Comfort

Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 8.3: Determine which techniques will ensure accurate measurement of vital signs.

MNL Learning Outcome: 8.1: Recognize the components of the general survey, including the functional assessment.

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. Which should the nurse document the client's blood pressure in this way? ________. Record your answer as a fraction.

Page Ref: 108

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Learning Outcome: 8.3: Determine which techniques will ensure accurate measurement of vital signs.

MNL Learning Outcome: 8.4: Apply the principles of assessing vital signs in patient care.

The nurse is assessing a 15-month-old client. Which arterial site should the nurse use to assessing the pulse?

1. Radial artery.

2. Brachial artery.

3. Apical site.

4. Carotid artery.

Page Ref: 108

Cognitive Level: Remembering

Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment

Learning Outcome: 8.3: Determine which techniques will ensure accurate measurement of vital signs.

MNL Learning Outcome: 8.4: Apply the principles of assessing vital signs in patient care.

The nurse educator is observing the student nurse take a blood pressure on an older adult client. In which instances should the educator intervene? Select all that apply.

1. The student nurse ushers the client into the exam room and immediately assesses the client's blood pressure.

2. The student nurse places the blood pressure cuff on the client's arm over a lightweight, long-sleeved sweater.

3. The student nurse immediately reinflates the cuff after identifying the palpatory systolic blood pressure.

4. The student nurse has the client sit in a chair and supports the client's arm on a table at the level of the heart.

5. The student nurse places the blood pressure cuff on the thigh of a client with a bilateral mastectomy and takes the blood pressure using the popliteal artery.

Page Ref: 107

Cognitive Level: Analyzing

Client Need & Sub: Safe and Effective Care Environment; Assignment, Delegation, and Supervision

Standards: QSEN Competencies: II.B.9. Explain how authority gradients influence teamwork and patient safety. | AACN Essentials Competencies: IX.14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the healthcare team. | NLN Competencies: Teamwork: Choose communication styles that diminish the risks associated with authority gradients among team members to accomplish care, assert one's own views, and minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 8.3: Determine which techniques will ensure accurate measurement of vital signs.

MNL Learning Outcome: 8.3: Examine the factors that influence the measured results of vital signs.

A mother brings her child into the clinic and states, "My child has had a fever the past few days because the skin has felt warm." Which response should the nurse provide the mother?

1. "When the skin feels warm, it means our blood vessels are constricted."

2. "The only way to reliably assess the temperature with your hand is by feeling the forehead."

3. "The skin temperature changes when the temperature in our surroundings changes."

4. "The temperature of the skin is not related to what is occurring inside the body."

Page Ref: 101

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: III.2. Demonstrate an understanding of the basic elements of the research process and models for applying evidence to clinical practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8.4: Interpret nurse-patient encounter findings accurately.

MNL Learning Outcome: 8.2: Explain the body's regulation of temperature, pulse, respirations, and blood pressure.

The nurse is assessing an older adult client with arteriosclerosis and obtains a blood pressure reading of 172/98 mmHg. Which physiological changes should the nurse recognize are associated with the blood pressure finding? Select all that apply.

1. Arteriosclerosis decreases the ventricular force necessary for ejection of blood.

2. Arteriosclerosis increases blood vessel elasticity.

3. Arteriosclerosis decreases blood vessel compliance.

4. Age decreases blood vessel elasticity.

5. Arteriosclerosis does not affect the blood pressure in older clients.

Page Ref: 106

Cognitive Level: Understanding

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 8.4: Interpret nurse-patient encounter findings accurately.

MNL Learning Outcome: 8.3: Examine the factors that influence the measured results of vital signs.

The nurse is preparing to obtain a pulse oximeter reading. Which should the nurse understand may provide a false reading? Select all that apply.

1. Long nails.

2. Artificial nails.

3. Pierced earlobe.

4. Polished nails.

5. Cool extremities.

Page Ref: p.105

Cognitive Level: Understanding

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Learning Outcome: 8.3: Determine which techniques will ensure accurate measurement of vital signs.

MNL Learning Outcome: 8.3: Examine the factors that influence the measured results of vital signs.

The nurse is preparing to assess the blood pressure of a client with a history of a left breast mastectomy. Which anatomical location should the nurse use to place the blood pressure cuff on?

1. Right arm.

2. Left thigh.

3. Left arm.

4. Right thigh.

Page Ref: 107

Cognitive Level: Applying

Client Need & Sub: Safety and Infection Control; Accident/Error/Injury Prevention

Learning Outcome: 8.3: Determine which techniques will ensure accurate measurement of vital signs.

MNL Learning Outcome: 8.4: Apply the principles of assessing vital signs in patient care.

The nurse is preparing to weigh a client on a digital scale. Which intervention should the nurse implement to obtain an accurate weight?

1. Calibrate the scale.

2. Ensure the scale has a capacity to hold greater than 159 kg.

3. Ask the client to remove their shoes.

4. Have the client stand on the scale facing backward.

Page Ref: 99

Cognitive Level: Understanding

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Learning Outcome: 8.2: Identify the necessary steps and equipment for measuring height and weight.

MNL Learning Outcome: 8.4: Apply the principles of assessing vital signs in patient care.

The nurse is preparing to measure the head circumference of an infant. Which technique should the nurse use?

1. Measure the head directly circumferentially around the forehead.

2. Measure the head around the occiput and above the eyebrows.

3. Measure around the most prominent part of the occiput and above the eyebrows.

4. Measure the crown of the head circumferentially.

Page Ref: 100

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment

Learning Outcome: 8.2: Identify the necessary steps and equipment for measuring height and weight.

MNL Learning Outcome: 8.4: Apply the principles of assessing vital signs in patient care.

The nurse observes that an adolescent client is wearing dirty clothes. Which initial risk factor should the nurse further assess the client for?

1. Substance abuse.

2. Lack of hygiene knowledge.

3. Neglect.

4. Low self-esteem.

Page Ref: 98

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity; Personal Hygiene

Learning Outcome: 8.4: Interpret nurse-patient encounter findings accurately.

MNL Learning Outcome: 8.1: Recognize the components of the general survey, including the functional assessment.

The nurse notes the client's oral temperature at 6 a.m. was 98.0°F and 99.2°F at 5:00 pm. Which should the nurse recognize is the reason for the variation?

1. Improper assessment.

2. Infection.

3. Stress.

4. Diurnal pattern.

Page Ref: 102

Cognitive Level: Analyzing

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Learning Outcome: 8.4: Interpret nurse-patient encounter findings accurately.

MNL Learning Outcome: 8.2: Explain the body's regulation of temperature, pulse, respirations, and blood pressure.

The nurse is providing education about blood pressure for a group of clients. Which information should the nurse include?

1. Females tend to have higher blood pressure readings than males of the same age.

2. Stress can result in an increase in blood pressure.

3. Blood pressure readings tend to be lowest in the evening.

4. During physical activity, blood pressure can slightly decrease.

Page Ref: 106

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention

Learning Outcome: 8.3: Determine which techniques will ensure accurate measurement of vital signs.

MNL Learning Outcome: 8.2: Explain the body's regulation of temperature, pulse, respirations, and blood pressure.

The educator has observed the nurse taking the blood pressure with the client's arm above the level of the heart. Which assessment finding does the educator anticipate?

1. False low reading.

2. False high reading.

3. High systolic, low diastolic reading.

4. Low systolic, high diastolic reading.

Page Ref: 107

Cognitive Level: Applying

Client Need & Sub: Health Promotion/Disease Prevention; Techniques of Physical Assessment

Learning Outcome: 8.3: Determine which techniques will ensure accurate measurement of vital signs.

MNL Learning Outcome: 8.3: Examine the factors that influence the measured results of vital signs.

The nurse is preparing to obtain an adult client's temperature with a tympanic thermometer. Which technique should the nurse use to obtain an accurate reading?

1. Pull the client's pinna up and back.

2. Pull the client's pinna down and back.

3. Place the covered probe at the opening of the ear.

4. Tilt the client's head to the opposite side.

Page Ref: 103

Cognitive Level: Applying

Client Need & Sub: Health Promotion/Disease Prevention; Techniques of Physical Assessment

Learning Outcome: 8.3: Determine which techniques will ensure accurate measurement of vital signs.

MNL Learning Outcome: 8.4: Apply the principles of assessing vital signs in patient care.

An unlicensed assistive personnel (UAP) reports an older adult's vital signs to nurse as follows: Temperature 97.4°F (oral), BP 165/70, pulse rate 84/min., and respirations 28. Which action should the nurse take?

1. Maintain routine vital signs.

2. Instruct the UAP to recheck the temperature.

3. Request a prescription for an antihypertensive.

4. Request oxygen therapy.

Page Ref: 109

Cognitive Level: Analyzing

Client Need & Sub: Health Promotion and Maintenance; Developmental Stages and Transitions

Learning Outcome: 8.3: Determine which techniques will ensure accurate measurement of vital signs.

MNL Learning Outcome: 8.3: Examine the factors that influence the measured results of vital signs.

An older client asks why their height has decreased by 1/4 of inch over past two years. Which response should the nurse provide?

1. "Your bones are weaker and are shrinking."

2. "Maybe you are mistaken about your actual height."

3. "Your height decreases with age due to musculoskeletal changes."

4. "Stand up straighter this time and we will measure again."

Page Ref: 101

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Developmental Stages and Transitions

Learning Outcome: 8.4: Interpret nurse-patient encounter findings accurately.

MNL Learning Outcome: 8.3: Examine the factors that influence the measured results of vital signs.

The nurse is reviewing the prescription for a client with pneumonia. The client's vital signs are: Temperature 101.2°F (oral), BP 100/70, pulse rate 110/min., respirations 22, and oxygen saturation 96%. Based on these findings, which order should the nurse seek clarification for?

1. Administer acetaminophen (Tylenol) 650 mg every 4 hours as needed for a temperature greater than 100.5°F.

2. Administer intravenous (IV) fluids: 0.9% Normal Saline Solution at 125 ml/hour.

3. Start oxygen therapy at 3L/minute via nasal cannula.

4. Schedule client for a chest x-ray.

Page Ref: 105

Cognitive Level: Analyzing

Client Need & Sub: Safe and Effective Care Environment; Collaboration with Interdisciplinary Team

Learning Outcome: 8.4: Interpret nurse-patient encounter findings accurately.

MNL Learning Outcome: 8.4: Apply the principles of assessing vital signs in patient care.

The nurse is preparing to assess the respiratory system of an infant. Which physiological differences between the infant and a child should the nurse consider?

1. Infants have thicker muscular chest walls.

2. Breath sounds may be more subtle.

3. Thoracic breathing is common.

4. Referred sounds from the upper airways are common.

Page Ref: 106

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Learning Outcome: 8.3: Determine which techniques will ensure accurate measurement of vital signs.

MNL Learning Outcome: 8.3: Examine the factors that influence the measured results of vital signs.

While interviewing a client, the nurse observes that the client is changing position frequently, wringing hands, and laughing at inappropriate times. Which assessment should the nurse perform?

1. Anxiety assessment.

2. Mental status testing.

3. Attention deficit testing.

4. Nutritional assessment.

Page Ref: 97

Cognitive Level: Applying

Client Need & Sub: Psychosocial Integrity; Coping Mechanisms

Learning Outcome: 8.1: Identify the components of the general survey.

MNL Learning Outcome: 8.1: Recognize the components of the general survey, including the functional assessment.

A client asks what the numbers in the blood pressure mean. Which statements should the nurse include in the response to the client? Select all that apply.

1. "Diastolic pressure, indicated by the bottom number, is the pressure in the arteries when the heart is at rest."

2. "Diastolic pressure is the arterial pressure between ventricular contractions."

3. "Systolic pressure, indicated by the top number, is the result of the heart rate."

4. "Systolic pressure, indicated by the top number, reflects the pressure in the arteries when the heart contracts and pumps blood into general circulation."

5. "Systolic pressure is the pressure at the height of the wave, when the left ventricle contracts."

Page Ref: 106

Cognitive Level: Applying

Client Need & Sub: Psychosocial Integrity; Therapeutic Communication

Learning Outcome: 8.4: Interpret nurse-patient encounter findings accurately.

MNL Learning Outcome: 8.3: Examine the factors that influence the measured results of vital signs.

Document Information

Document Type:

DOCX

Chapter Number:

Created Date:

Aug 21, 2025

Chapter Name:

Chapter 8 General Survey and Physical Exam Objective Data

Author:

Cynthia Fenske

Connected Book

Health Assessment in Nursing 4e Test Bank

By Cynthia Fenske

Test Bank General

View Product →

Explore recommendations drawn directly from what you're reading

Chapter 6 Documentation

DOCX Ch. 6

Chapter 7 Physical Assessment Techniques and Equipment

DOCX Ch. 7

Chapter 8 General Survey and Physical Exam Objective Data

DOCX Ch. 8 Current

Chapter 9 Pain Assessment

DOCX Ch. 9

Chapter 10 Nutritional Assessment

DOCX Ch. 10

$24.99

100% satisfaction guarantee

Buy Full Test Bank

Quick Navigation

Preview Document Info Connected Book Recommendations

Benefits

Immediately available after payment

Answers are available after payment

ZIP file includes all related files

Files are in Word format (DOCX)

Check the description to see the contents of each ZIP file

We do not share your information with any third party

Test Bank + Answers Ch8 General Survey and Physical Exam

Health & Physical Assessment in Nursing, 4e (Fenske/Watkins/Saunders/D'Amico/Barbarito)

Chapter 8 General Survey and Physical Exam: Objective Data

Document Information

Connected Book

Health Assessment in Nursing 4e Test Bank

Explore recommendations drawn directly from what you're reading

$24.99

Quick Navigation

Benefits

Report Unauthorized Use

Added to Cart