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, respiratory rate 16.
2. Thin, well-nourished male client, appears younger than stated age.
3. Client moves about exam room without difficulty.
4. Abdomen flat, nondistended, bowel sounds present, nontender on palpation.
5. Pain rating of 3 on a 0 to 10 scale.
Correct Answer: 2, 3
The general survey is composed of four major categories of observation: physical appearance, mental status, mobility, and behavior of the client. The documentation thin, well-nourished male client, appears younger than stated age reflects the client's physical appearance, one of the components of the general survey. The documentation client moves about exam room without difficulty describes the client's overall mobility, another component of the general survey. The vital signs are objective information, but not part of the actual general survey. The documentation abdomen flat, nondistended, bowel sounds present, nontender on palpation is specific to the abdominal assessment and not part of the general survey. A pain assessment is included when assessing the client's vital signs.
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