Which general survey question focuses on the common "fifth vital sign"?

"When was the last time you experienced a fever?"

"Do you consider yourself a happy person?"

"Do you monitor your blood pressure regularly?"

"Are you experiencing any pain right now?"

Answer and Explanation

The Correct Answer is D

A. "When was the last time you experienced a fever?": This question pertains to the assessment of body temperature, which is part of the vital signs but not the "fifth vital sign."

B. "Do you consider yourself a happy person?": This question focuses on emotional well-being, not the "fifth vital sign."

C. "Do you monitor your blood pressure regularly?": This pertains to blood pressure monitoring, which is one of the vital signs but not the "fifth vital sign."

D. "Are you experiencing any pain right now?": Pain is often referred to as the "fifth vital sign" and is assessed to understand a patient's overall health and comfort.

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Correct Answer is A

Explanation

A. Tuning fork: A tuning fork is used in auditory assessments, such as hearing tests, to evaluate hearing loss and bone conduction.

B. Stethoscope: While a stethoscope is essential for auscultation of heart and lung sounds, it is not used for examining the ears.

C. Ophthalmoscope: An ophthalmoscope is used for examining the eyes, not the ears.

D. Tongue depressor: A tongue depressor is used for examining the mouth and throat, not the ears.

A. Use tangential lighting. B. Assist the client to a standing position. C. Use perpendicular lighting. D. Focus a penlight on the client's chest.

Correct Answer is C

Explanation

A. Use tangential lighting: Tangential lighting is not typically used for assessing heart impulses; it is more useful for examining surface characteristics of the skin.

B. Assist the client to a standing position: The client should be in a supine or semi-recumbent position for accurate inspection of apical heart impulses, not standing.

C. Use perpendicular lighting: Perpendicular lighting is crucial for accurately visualizing apical heart impulses, as it helps to clearly observe the movement of the heart against the chest wall.

D. Focus a penlight on the client's chest: While a penlight can be used in physical assessments, perpendicular lighting is more effective for clearly seeing the apical heart impulses.

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Which general survey question focuses on the common "fifth vital sign"?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing a head-to-toe assessment and is preparing to examine the client's ears. Which equipment would the nurse need to have readily available?

Correct Answer is A

Explanation

The nurse is planning to inspect a client's apical heart impulses. What should the nurse do to ensure an accurate assessment of this organ?

Correct Answer is C

Explanation

Use of tobacco products and excessive alcohol consumption are principal risk factors for oral carcinoma.

Cranial nerves involved in eye movements are:

When performing a head-to-toe assessment, during which part would the nurse assess the sensory function of cranial nerve VIII?

During a health history, which of the following can the nurse ask to determine an older adult client's abilities to conduct instrumental activities of daily living? (Select all that apply.)

The nurse is conducting a health history with a female client who reports upper back and jaw pain. In order to assess the client's risk for a cardiac event, which question should the nurse ask first?

A positive Murphy's sign is indicative of?

What eye function is the nurse preparing to assess when the client is asked to stand 20 feet from a specific chart that is mounted on the examination room wall?

The nurse is asking the client about the health of her parents, siblings, and grandparents. This is part of the health history and is done for what reason?