The nurse notices the client's physical appearance, behavior, mobility, and neurological status when they enter the room.
Which of the following is the nurse assessing?

General survey.

Medical history.

Biographical data.

Social history.

Answer and Explanation

The Correct Answer is A

Choice A rationale

The general survey is an overall assessment of a client's physical appearance, behavior, mobility, and neurological status. It provides a comprehensive overview of the client's health and well-being, making it the focus of the nurse's observations in this scenario.

Choice B rationale

Medical history includes past and current health conditions, surgeries, medications, and family health history. While important, it is not the focus of the nurse's immediate observations in this scenario.

Choice C rationale

Biographical data involves personal information such as age, gender, occupation, and marital status. While relevant to the client's health, it is not the primary focus of the nurse's observations in this scenario.

Choice D rationale

Social history includes information about the client's lifestyle, habits, and social environment. While valuable for understanding the client's overall health context, it is not the focus of the nurse's immediate observations in this scenario. .

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Correct Answer is A

Explanation

Choice A rationale

The Cover/Uncover test is used to assess the presence of strabismus or eye muscle weakness. During this test, one eye is covered while the other eye is observed for movement. The uncovered eye is then observed when the cover is removed. If there is a misalignment or weakness, the uncovered eye will move to re-establish focus, indicating a problem with eye muscle control.

Choice B rationale

Testing peripheral vision involves assessing the range of vision around the central focus point and is not specifically used to detect eye muscle weakness. It evaluates the function of the retina and optic nerve rather than the eye muscles. This test helps identify issues such as glaucoma or retinal detachment.

Choice C rationale

The Snellen chart test measures visual acuity, specifically how well a person can see at various distances. It is not designed to assess eye muscle strength or alignment. The test involves reading letters of different sizes from a chart placed at a standard distance.

Choice D rationale

The Weber test is an auditory test used to assess hearing loss by placing a vibrating tuning fork on the forehead or middle of the head. It helps determine whether hearing loss is conductive or sensorineural in nature. This test does not provide information about eye muscle function or alignment.

A. Romberg test. B. Weber test. C. Rinne test. D. Cover test.

Correct Answer is A

Explanation

Choice A rationale

The Romberg test evaluates equilibrium by having the client stand with feet together and eyes closed, observing for swaying or imbalance. It assesses the function of the vestibular system, proprioception, and cerebellar function, making it the most appropriate test for assessing dizziness and equilibrium.

Choice B rationale

The Weber test involves placing a tuning fork on the forehead to evaluate sound lateralization. It assesses hearing loss but not equilibrium, making it less suitable for dizziness assessment.

Choice C rationale

The Rinne test compares air and bone conduction of sound using a tuning fork. While useful for diagnosing conductive hearing loss, it does not assess equilibrium, making it inappropriate for evaluating dizziness.

Choice D rationale

The cover test evaluates eye alignment and muscle function by having the client cover one eye and observe the uncovered eye for movement. It assesses ocular motility but not equilibrium, making it unsuitable for dizziness assessment.

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Which of the following is the nurse assessing?