The nurse observes the client walking into the room and climbing ...

[student77]

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 status.
  2. Subjective assessments related to ambulation.
  3. Activity tolerance.
  4. Strength of upper and lower extremities.

Question 2

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?
 
  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.

[kalskdjl1212]

Answer to Question 1

Correct Answer: 1

During a general survey, the nurse observes the client performing routine activities, such as walking and sitting. This allows the nurse to begin to gather data about the client's mobility. These data will then be incorporated into the remainder of exam and history. Observation is an objective assessment. Activity tolerance is not a component of the general survey. The general survey consists of physical appearance, mental status, mobility, and behavior. Watching the client walk and sit gives the nurse information about the strength of a client's lower extremities, but tells the nurse nothing about the client's upper extremity strength.

Answer to Question 2

Correct Answer: 3

The general survey allows the nurse to observe the client and gain clues to guide the remainder of the assessment. Vital signs are not part of the general survey. The purpose of the general survey is to allow the nurse the opportunity to gather clues to guide the rest of the assessment; the purpose is not to give the client an opportunity to relax. The general survey consists of four major observations: physical appearance, mental status, mobility, and behavior. The general survey does not provide the necessary information to identify client problems or nursing diagnosis, but rather serves as a guide for a more detailed assessment.