Module 2: General Survey

what is the general survey?

the initial appraisal of the client’s overall presentation, appearance, and behaviors

which finding is assessed under appearance?

mental status

which finding is included when assessing behavior?

speech

what is part of body structure assessment?

posture

which measurements are anthropometric measurements?

height, weight, and BMI

which assessment is considered the subjective vital sign?

pain

what does assessment of appearance provide?

initial cues about neurological, psychiatric, and psychological conditions

which facial finding is expected?

symmetric smile and eye closure

an expressionless or mask like face may indicate which condition?

Depression or Parkinson’s disease

a drooping eyelid is called what?

ptosis

what may facial asymmetry with one side of the mouth drooping indicate?

stroke or bell’s palsy

which facial finding is unexpected?

involuntary twitching

which emotional presentation is expected?

calm and relaxed

what should the nurse consider when interpreting eye contact behaviors?

cultural background

what does A&O x4 stand for?

alert and oriented to person, place, time, and situation

what condition is characterized by acute, sudden, fluctuating confusion?

delirium

which condition is characterized by chronic, progressive confusion?

dementia

which level of consciousness requires loud auditory or physical to arouse the client?

obtundation

a client who responds to pain with movement or incoherent vocalizations is demonstrating what?

stupor

what does pallor describe?

skin lighter than the surrounding skin

what is cyanosis characterized by?

a bluish skin tone

what can cyanosis indicate?

hypoxia or poor perfusion

jaundice is characterized by what?

yellow skin

what is jaundice associated with?

bilirubin buildup or liver dysfunction

erythema refers to what?

red to purple skin

what may erythema be associated with?

inflammation, infection, or fever

what speech characteristics should the nurse assess?

fluency, pace, and articulation

what can a hoarse or whispering voice indicate?

laryngeal disease or strain

what is dysarthria?

slurred, garbled, or difficult-to-articulate speech

what is aphasia?

difficulty finding, expressing, or understanding language

what is echolalia?

repetitive parroting of words

what is mood?

the client’s internal emotional state

what is affect?

how the client’s mood appears to others

what is flat affect?

an expressionless, unresponsive face that does not change with conversation

what is halitosis?

bad breath

what can fruity breath indicate?

diabetic ketoacidosis

what is ammonia breath often associated with?

advanced kidney disease

a fetid odor can suggest what?

deep dental, oral, or respiratory infection

fecal breath odor may indicate what?

bowel obstruction with vomiting

what does a plumb line represent?

a vertical line through the outer ear, shoulder, hip, patella, and ankle

a stiff spine and neck moving as one unit may indicate what?

pain or severe arthritis

uneven weight distribution in the face, neck, and trunk may indicate what?

cushing’s syndrome

what is crepitus?

a cracking, popping, or grating sound from joint surfaces rubbing

what is spasticity?

increased muscle tone with increased resistance to passive extension

what is fasciculation?

continuous, rapid, fine muscle twitching at rest

what is rigidity?

resistance to passive manipulation regardless of speed

which movement is an example of myoclonus?

sudden shock-like jerking

what device should be used to measure the height of a standing client?

stadiometer

how should height be measured for a client unable to stand?

supine from crown of the head to the bottom of the heel

what should the nurse do before using a balancing scale?

set it ot zero

for frequent weight monitoring, which approach provides the most consistent measurements?

same time, scale, type of clothing

a gain of approximately five pounds in one day is a warning sign for what?

acute fluid retention

rapid weight gain of 5 pounds in one day is commonly associated with worsening what?

heart failure

which weight loss is considered clinically significant?

5% within one month

which additional amount of unintentional weight loss is significant?

10% within 6 months

a BMI below 18.5 is classified as what?

underweight

a BMi of 18.5-24.9 is classified as what?

healthy weight

a BMI of 25.0-29.9 is classified as what?

overweight

a BMI of 30 or greater is classified as what?

obese

a high BMI of 30 or greater increases the risk for what?

hypertension and type 2 diabetes

poor nutrition associated with low BMI can increase the risk for what?

infection and delayed wound healing

which gastrointestinal symptoms should be assessed when evaluating low BMI?

nausea, vomiting, diarrhea, and heartburn

which social factor should the nurse assess when evaluating low BMI?

ability to afford food

what is the expected core body temperature range?

96.8 - 100.4 degrees fahrenheit , 36 - 38 degrees celsius

a core temperature is typically how much higher than surface skin temperature?

0.5 degrees celsius

which part of the brain regulates body temperature?

hypothalamus

which hypothalamic region regulates heat loss?

anterior hypothalamus

which hypothalamic region regulates heat production and conservation?

posterior hypothalamus

which response helps the body lose height?

vasodilation and sweating

which response helps conserve or produce heat?

vasoconstriction and shivering

when does body temperature generally peak?

around 4pm

when is body temperature generally lowest?

early morning, approximately 1-4am

which temperature route is most commonly used?

oral

how long should a client wait after smoking, eating, or drinking hot/cold liquids before an oral temperature?

ten minutes

which route provides the most accurate core temperature?

rectal

which client is an appropriate candidate for a rectal temperature?

a comatose client

which is a contraindication to rectal temperature measurement?

thrombocytopenia and active diarrhea

where is a temporal thermometer briefly placed after sliding it across the forehead?

behind the earlobe

which temperature route is safest but least accurate?

axillary

which temperature route is rarely used in adults?

axillary

which factor can make a tympanic temperature inaccurate?

heavy earwax

which formula converts fahrenheit to celsius?

(F-32) x 5/9

which formula converts celsius to fahrenheit?

(9/5 x C) + 32

a temperature of 102 degrees Fahrenheit would be classified as what?

hyperthermia/fever

hypothermia is characterized by what?

core temperature below expected limits

what does a peripheral pulse represent?

expansion of an artery as the heart contracts

which pulse site is primary for a stable client?

radial

which pulse site may be used when a client is unstable or has poor cardiac output?

apical

which pulse site is located in the neck?

carotid

what should be applied before using a doppler to assess a diminished pulse?

transmission gel

at what angle should the transducer be placed?

90 degrees

what sound should be heard when locating a pulse with doppler?

whooshing

which fingers should be used to palpate a peripheral pulse?

index and middle finger pads

how long should a regular pulse be counted?

30 seconds x 2

how long should an irregular pulse be counted?

Full 60 seconds

what is the expected adult resting heart rate?

60-100bpm

a resting heart rate below 60bpm is called what?

bradycardia

bradycardia may be an expected finding in who?

highly conditioned athletes

which condition can cause pathological bradycardia?

hypothyroidism

when bradycardia is detected, what should the nurse assess?

apical pulse