Before completing the physical examination, the nurse determines that the client is awake, alert, and oriented. This information would be important for which part of the general survey?

Apparent state of health

Facial expression

Level of consciousness

Posture, gait, motor activity, and speech

Answer and Explanation

The Correct Answer is C

A. Apparent state of health: This generally reflects overall health rather than specific mental or cognitive status.

B. Facial expression: Facial expression provides insight into mood and emotional state but does not specifically assess consciousness or orientation.

C. Level of consciousness: Being awake, alert, and oriented is directly related to the level of consciousness, which is a key aspect of assessing cognitive and mental function.

D. Posture, gait, motor activity, and speech: These aspects are relevant for physical activity and motor skills, not specifically for consciousness or cognitive orientation.

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Correct Answer is ["A","D"]

Explanation

A. Wait until the end of the physical assessment to reassess the radial pulse: If the radial pulse is irregular, it is important to reassess it to confirm irregularity. However, waiting until the end of the assessment is not recommended; it is better to reassess promptly.

B. Reassess the client's pedal pulse on the other foot: This is not related to assessing the regularity of the radial pulse.

C. Assess the client's 51 and 52 sounds for regularity: These terms are not standard in assessing pulse regularity; the focus should be on the apical pulse for an irregular radial pulse.

D. Assess the client's apical pulse for a full minute: The apical pulse should be assessed for a full minute to accurately determine the heart rate and rhythm, especially if the radial pulse is irregular.

A. S4 heart sound B. Harsh holosystolic murmur at the apex C. S3 heart sound D. Carotid bruits

Correct Answer is C

Explanation

A. S4 heart sound: An S4 heart sound is often associated with hypertensive heart disease or left ventricular hypertrophy, rather than congestive heart failure alone.

B. Harsh holosystolic murmur at the apex: This type of murmur is more indicative of mitral regurgitation rather than congestive heart failure.

C. S3 heart sound: An S3 heart sound is commonly associated with congestive heart failure, especially when there is volume overload and decreased left ventricular function.

D. Carotid bruits: Carotid bruits are associated with vascular issues rather than congestive heart failure.

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Before completing the physical examination, the nurse determines that the client is awake, alert, and oriented. This information would be important for which part of the general survey?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During a physical assessment, the nurse should implement which actions initially when determining if a client's radial pulse is irregular? (Select all that apply.)

Correct Answer is ["A","D"]

Explanation

The nurse suspects an older adult client has congestive heart failure. Which of the following did the nurse most likely assess in the client?

Correct Answer is C

Explanation

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