The nurse is assessing an adult client. Which of the following observations should the nurse include when documenting the general survey of this client? Standard Text: 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. Responds appropriately to questions.
2,3,5
Rationale 1: Blood pressure 112/68, pulse 68, 98.6 (F), respiratory rate 16. The vital signs are objective information, but not part of the actual general survey.
Rationale 2: Thin, well-nourished male client, appears younger than stated age. The general survey is composed of 4 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.
Rationale 3: Client moves about exam room without difficulty. The documentation client moves about exam room without difficulty describes the client's overall mobility, another component of the general survey.
Rationale 4: Abdomen flat, nondistended, bowel sounds present, nontender on palpation. The documentation abdomen flat, nondistended, bowel sounds present, nontender on palpation is specific to the abdominal assessment and not part of the general survey.
Rationale 5: Responds appropriately to questions. The documentation responds appropriately to questions comments on the nurse's observations regarding the client's behavior and mental status, 2 other components of the general survey.
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