Nursing Assessment: General Survey and Temperature

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Questions and Answers

Which of the following is NOT a component of the general survey?

  • Overall impression of the client
  • Mental status examination
  • Vital signs
  • Detailed neurological examination (correct)

What is the primary purpose of the general survey?

  • To evaluate the effectiveness of treatment
  • To diagnose specific conditions
  • To assess the client's specific complaints
  • To gather objective information about the client's overall health (correct)

Which of the following is an aspect that is NOT assessed during the 'Overall impression of the client' component of the General Survey?

  • Client's medical history (correct)
  • Client's appearance
  • Client's mobility
  • Client's physique

Which of the following is NOT assessed during the 'Mental Status Examination' component of the General Survey?

<p>Client's vital signs (A)</p> Signup and view all the answers

What is the correct order of the components of the general survey?

<p>Overall impression of the client, mental status examination, vital signs (D)</p> Signup and view all the answers

Choose the correct type of tissue that contributes to surface temperature.

<p>Adipose tissue (D)</p> Signup and view all the answers

Which of the following is NOT a factor affecting body temperature?

<p>Genetics (B)</p> Signup and view all the answers

Which of the following mechanisms helps decrease heat loss from the body?

<p>Vasodilation (D)</p> Signup and view all the answers

What is the medical term for the cycle of temperature fluctuations that occur naturally throughout the day?

<p>Circadian rhythm (C)</p> Signup and view all the answers

What is the most accurate way to measure core body temperature?

<p>Rectally (D)</p> Signup and view all the answers

Which of the following is NOT a method to assess body temperature?

<p>Using a stethoscope (A)</p> Signup and view all the answers

What is the primary mechanism the body utilizes to increase heat production?

<p>Shivering (D)</p> Signup and view all the answers

What is the role of vasoconstriction in temperature regulation?

<p>To decrease heat loss (B)</p> Signup and view all the answers

Which of the following is NOT a factor that can influence pulse rate?

<p>Age (D)</p> Signup and view all the answers

What is the normal respiratory rate for an adult at rest?

<p>12-16 breaths per minute (A)</p> Signup and view all the answers

What does the systolic blood pressure measure?

<p>The force of the blood pushing against the artery walls each time the heart beats (B)</p> Signup and view all the answers

Which of these is NOT a component assessed when examining pulse?

<p>Color (D)</p> Signup and view all the answers

What is the measurement unit for blood pressure?

<p>Millimetres of mercury (mm Hg) (B)</p> Signup and view all the answers

Who typically has a higher heart rate: Females or Males?

<p>Females aged 12 and older (A)</p> Signup and view all the answers

Why is pain considered the fifth vital sign?

<p>It's a common symptom that indicates various medical conditions (A)</p> Signup and view all the answers

What is the highest blood pressure category?

<p>Hypertensive crises (D)</p> Signup and view all the answers

Match the component of the General Survey with its description:

<p>Overall Impression of the Client = Objectively observing the client's appearance, mobility, and physique. Mental Status Examination = Structured assessment of the patient's behavioral and cognitive functioning. Vital Signs = Measurement of physiological indicators such as temperature, pulse, respiration, and blood pressure. General Survey = The first step in a head-to-toe assessment that provides information about the client's overall health.</p> Signup and view all the answers

Match the aspect assessed during the Mental Status Examination with its corresponding description:

<p>Level of Consciousness = Noting posture, body movements, and responsiveness. Appearance and General Behavior = Observing grooming, dress, hygiene, and overall comportment. Mood and Affect = Assessing the individual's emotional state and outward expression. Thought and Perception = Examining the clarity, coherence, and content of the individual's thinking.</p> Signup and view all the answers

Match the vital sign with its typical measurement unit:

<p>Temperature = Degrees Celsius (°C) or Fahrenheit (°F) Pulse = Beats per minute (bpm) Respiration = Breaths per minute (bpm) Blood Pressure = Millimeters of mercury (mmHg)</p> Signup and view all the answers

Match the factor influencing pulse rate with its description:

<p>Exercise = Increases heart rate to meet the body's increased oxygen demand. Age = Infants and children have faster pulse rates than adults. Emotions = Stress, anxiety, and excitement can elevate pulse rate. Medications = Certain drugs can affect heart rate, either increasing or decreasing it.</p> Signup and view all the answers

Match the assessment characteristic with its associated vital sign:

<p>Rhythm and Strength = Pulse Depth and Effort = Respiration Systolic and Diastolic = Blood Pressure Oral, Axillary, Rectal = Temperature</p> Signup and view all the answers

Match the following methods for assessing body temperature with their associated measurement locations:

<p>Orally = Mouth Rectally = Rectum Axillary = Armpit By ear = Ear canal</p> Signup and view all the answers

Match the following factors affecting body temperature with their potential influence:

<p>Age = Variations in normal temperature range Diurnal variations = Temperature fluctuations throughout the day Exercise = Increased heat production Stress = Hormonal changes affecting temperature regulation</p> Signup and view all the answers

Match the following body temperature regulation mechanisms with their respective actions:

<p>Shivering = Increased heat production Sweating = Increased heat loss Vasoconstriction = Decreased heat loss Vasodilation = Increased heat loss</p> Signup and view all the answers

Match the following types of body temperature with their corresponding tissue locations:

<p>Core temperature = Deep tissues such as abdominal and pelvic cavities Surface temperature = Subcutaneous tissue and fat</p> Signup and view all the answers

Match the following components of the general survey with their respective assessment methods:

<p>Overall impression of the client = Visual observation and interaction with the client Mental status Examination = Assessment of the client's cognitive function and behavior Vital Signs = Measuring temperature, pulse, respiration, and blood pressure Physical Examination = Detailed assessment of the client's body systems</p> Signup and view all the answers

Match the following methods for assessing pulse with their description:

<p>Palpation = Feeling the pulse with fingertips Auscultation = Listening to the pulse with a stethoscope Doppler = Using ultrasonic waves to detect blood flow</p> Signup and view all the answers

Match the following components of blood pressure with their descriptions:

<p>Systolic pressure = Pressure in the arteries when the heart contracts Diastolic pressure = Pressure in the arteries when the heart relaxes Pulse pressure = Difference between systolic and diastolic pressure</p> Signup and view all the answers

Match each component of the general survey with its corresponding description:

<p>Pulse = A measurement of the heart rate, often assessed at multiple locations. Respiration = The number of breaths a person takes per minute. Blood Pressure = The force of blood pushing against the artery walls. Pain = Often considered the fifth vital sign, providing insight into a person's overall health.</p> Signup and view all the answers

Match each component of the blood pressure measurement with its associated description:

<p>Systolic Pressure = Measured when the heart contracts and pumps blood. Diastolic Pressure = Measured when the heart is at rest and filling with blood. mm Hg = The unit of measurement for blood pressure. Blood Pressure Categories = Classifications ranging from normal to hypertensive crises based on pressure readings.</p> Signup and view all the answers

Match each aspect of pulse assessment with its corresponding description:

<p>Rate = Number of heartbeats per minute. Rhythm = Regularity or irregularity of the pulse. Amplitude = Strength or intensity of the pulse. Contour and Elasticity = Shape and flexibility of the blood vessels.</p> Signup and view all the answers

Match each factor with its potential impact on pulse rate:

<p>Exercise = Increases pulse rate. Illness = May increase pulse rate. Injury = May increase pulse rate. Emotions = Can fluctuate and increase pulse rate.</p> Signup and view all the answers

Match the factors with their potential influence on the respiratory rate:

<p>Fever = Increases respiratory rate. Illness = May increase respiratory rate. Other Medical Conditions = May increase respiratory rate. Rest = Normal respiratory rate ranges from 12 to 16 breaths per minute.</p> Signup and view all the answers

Match each blood pressure category with its corresponding range:

<p>Normal Blood Pressure = &lt; 120 / 80 Elevated Blood Pressure = 120 – 129 / 80 Stage 1 Blood Pressure = 130 – 139 / 80 Stage 2 Blood Pressure = ≥ 140 / 90.</p> Signup and view all the answers

Match each factor with its impact on heart rate:

<p>Females (aged 12 and older) = Tend to have faster heart rates than males. Athletes with Cardiovascular Conditioning = May have heart rates near 40 beats per minute. General Survey = Involves assessing pulse rate, respiration, and blood pressure. Pain = Often considered the fifth vital sign, reflecting a person's health.</p> Signup and view all the answers

Match each aspect of the circulatory system with its relevant characteristic:

<p>Arteries = Expand and contract with the flow of blood. Pulse Rate = Measurement of heart rate, representing the number of beats per minute. Normal Pulse Rate for Adults = Ranges from 60 to 100 beats per minute. Blood Pressure = The force of blood pushing against artery walls.</p> Signup and view all the answers

Which of these findings indicates that a client is obtunded?

<p>Client opens eyes to loud voice, responds slowly with confusion, seems unaware of environment (D)</p> Signup and view all the answers

What is the most appropriate action to take if a client does not respond to a gentle shake during the mental status assessment?

<p>Apply a painful stimulus to elicit a response. (B)</p> Signup and view all the answers

What is the primary purpose of the mental status assessment?

<p>To evaluate a client’s emotional and cognitive functional statuses. (B)</p> Signup and view all the answers

Which of these levels of consciousness indicates the client is the least responsive?

<p>Coma (B)</p> Signup and view all the answers

Which of the following statements about the mental status assessment is FALSE?

<p>It can be conducted only in a hospital setting. (A)</p> Signup and view all the answers

What is the most appropriate way to assess a client's level of consciousness during the mental status assessment?

<p>Observing the client's eye contact and response to questions. (A)</p> Signup and view all the answers

Which level of consciousness is characterized by a client who awakens to vigorous shake or painful stimuli, but returns to unresponsive sleep?

<p>Stupor (B)</p> Signup and view all the answers

What is the recommended approach to ensure a client's comfort and confidentiality during a mental status assessment?

<p>Conduct the assessment in a private setting, respecting the client's boundaries. (A)</p> Signup and view all the answers

Which of the following is a key aspect of the 'Generativity vs Stagnation' stage in psychosocial development, as described in the text?

<p>Contributing to the betterment of others and the community (B)</p> Signup and view all the answers

Which of the following abnormal findings, observed during a mental status assessment, suggests a possible diagnosis of depression?

<p>Slumped posture and poor eye contact (A)</p> Signup and view all the answers

What is a primary characteristic of the 'Ego Integrity vs Despair' stage of psychosocial development?

<p>Reconciling with past mistakes and achieving a sense of self-acceptance (A)</p> Signup and view all the answers

A client exhibiting abnormal flexor posture (decorticate) is likely to have a lesion in which part of the nervous system?

<p>Corticospinal tract (C)</p> Signup and view all the answers

What is the time frame specified in the text for the 'Young Adult' stage of psychosocial development?

<p>21 to 39 years (B)</p> Signup and view all the answers

Which abnormal postural finding, seen during the general survey, is associated with a potential diagnosis of mania?

<p>Prolonged, euphoric laughing (C)</p> Signup and view all the answers

Which of the following is NOT a key point of the 'Intimacy vs Isolation' stage of psychosocial development?

<p>Successfully navigating career advancement and professional success (A)</p> Signup and view all the answers

What does a client exhibiting the abnormal extensor posture (decerebrate) likely have?

<p>A lesion in the brainstem (D)</p> Signup and view all the answers

What is an essential aspect of the 'Generativity vs Stagnation' stage that promotes successful development?

<p>Creating a sense of purpose and leaving a positive impact on the community (C)</p> Signup and view all the answers

During a mental status assessment, which abnormal finding may be indicative of both depression and obsessive-compulsive disorder?

<p>Inappropriate dress and poor hygiene (B)</p> Signup and view all the answers

Within the 'Ego Integrity vs Despair' stage, what is a primary challenge for older adults as discussed in the text?

<p>Adjusting to the physical changes and limitations associated with aging (A)</p> Signup and view all the answers

What is the key concept associated with the 'Intimacy vs Isolation' stage of psychosocial development, as described in the text?

<p>Building and nurturing close relationships with others, fostering a sense of belonging (D)</p> Signup and view all the answers

Which of the following is NOT an abnormal finding commonly observed in individuals affected by depression?

<p>Loud, rapid speech (A)</p> Signup and view all the answers

During the mental status assessment, what abnormal finding may be indicative of schizophrenia or medication side effects?

<p>Bizarre body movements and behavior (D)</p> Signup and view all the answers

Which of the following is NOT a key element of the assessment questions for the 'Generativity vs Stagnation' stage as outlined in the text?

<p>Does the client have a good support network of friends and family? (B)</p> Signup and view all the answers

Which of the following is a normal finding observed during the mental status assessment?

<p>Moderate tone, clear and moderate-paced speech (A)</p> Signup and view all the answers

What is the developmental stage that corresponds to the age range of 18 months to 3 years according to Erikson's stages?

<p>Autonomy vs. Shame and Doubt (B)</p> Signup and view all the answers

During the 'Autonomy vs. Shame and Doubt' stage (18 months – 3 years), which of the following developmental milestones is NOT directly observed?

<p>Development of abstract thinking skills (B)</p> Signup and view all the answers

What is the primary focus of the 'Imitative vs. Guilt' stage of Erikson's psychosocial development model?

<p>Exploring and developing imagination and creativity (A)</p> Signup and view all the answers

Which of the following statements about the 'Industry vs. Inferiority' stage (6-12 years) is TRUE?

<p>Children develop a sense of competence and accomplishment through mastering new skills and tasks (B)</p> Signup and view all the answers

What is the primary developmental challenge of the 'Identity vs. Role Confusion' stage (13-18 years) according to Erikson?

<p>Establishing a strong sense of self-identity and purpose (C)</p> Signup and view all the answers

Which of the following is NOT a sample interview question relevant to the 'Autonomy vs. Shame and Doubt' stage?

<p>Does your child demonstrate strong problem-solving skills in novel situations? (B)</p> Signup and view all the answers

Which of the following questions would be most relevant to assess the child's development in the 'Industry vs. Inferiority' stage?

<p>Does your child interact well with peers and authority figures like teachers? (D)</p> Signup and view all the answers

Which Erikson stage is characterized by the individual's exploration of various roles, beliefs, and values to develop a stable sense of identity?

<p>Identity vs. Role Confusion (D)</p> Signup and view all the answers

Which of the following is NOT considered a potential negative impact of religious beliefs on health, as discussed in the text?

<p>Increased reliance on prayer for healing (C)</p> Signup and view all the answers

What is the primary purpose of the FICA© tool for spiritual assessment?

<p>To understand the patient's faith-based beliefs and their influence (A)</p> Signup and view all the answers

Which of these questions focuses on the "I" component of the FICA© tool during a spiritual assessment?

<p>Is it important in your life? (B)</p> Signup and view all the answers

Which of the following is NOT mentioned within the 'F' component of the FICA© tool?

<p>How have your beliefs influenced your behavior during this illness? (C)</p> Signup and view all the answers

Which question from the spiritual assessment tool addresses the "C" component of the FICA©?

<p>Are you part of a spiritual or religious community? (C)</p> Signup and view all the answers

What is the role of spirituality in relation to health, particularly in chronic disease management?

<p>Spirituality has been associated with greater well-being and positive health outcomes (B)</p> Signup and view all the answers

Which of the following is a recommendation for taking a spiritual history mentioned in the text?

<p>Acknowledge spirituality as a relevant factor in patient well-being (B)</p> Signup and view all the answers

Which of the following is a potential positive outcome associated with spirituality in certain populations?

<p>Lower levels of stress and depression (C)</p> Signup and view all the answers

When assessing a client's thought process and perception, which of the following could indicate an abnormal finding?

<p>Client exhibits illogical thoughts and a rapid flight of ideas. (C)</p> Signup and view all the answers

During the assessment of cognitive abilities, which of the following would typically be considered a normal finding for orientation?

<p>The client demonstrates a strong understanding of their identity, the time, and the location. (B)</p> Signup and view all the answers

To assess a client's ability to learn new information, a nurse would typically use which of the following methods?

<p>Having the client repeat four unrelated words at various intervals. (C)</p> Signup and view all the answers

Which of the following scenarios would be considered an appropriate method to assess a client's judgment?

<p>Presenting the client with a hypothetical situation and asking them to describe how they would respond. (C)</p> Signup and view all the answers

When assessing a client's visual perception and constructional ability, which of the following is NOT a typical task?

<p>Asking the client to describe their preferred color. (C)</p> Signup and view all the answers

In which of the following circumstances would a nurse be likely to employ the Mini-Mental Status Examination (MMSE)?

<p>To screen for cognitive impairment or cognitive loss. (B)</p> Signup and view all the answers

If a client demonstrates difficulty understanding or using proverbs appropriately, it could suggest which of the following?

<p>The client may have a cognitive impairment such as dementia or schizophrenia. (C)</p> Signup and view all the answers

Which of the following would be categorized as an abnormal finding when observing a client's mood and expressions?

<p>A client remains quiet and withdrawn during the interview. (B)</p> Signup and view all the answers

A client who is obtunded can be aroused only by a painful stimulus.

<p>False (B)</p> Signup and view all the answers

If a client does not respond to being called by name, the next step in assessing level of consciousness is to gently shake them.

<p>True (A)</p> Signup and view all the answers

Lethargy is a deeper level of consciousness than obtunded.

<p>False (B)</p> Signup and view all the answers

A client in a coma is unresponsive to all stimuli, but their eyes remain open.

<p>False (B)</p> Signup and view all the answers

The mental status assessment only evaluates cognitive function, not emotional function.

<p>False (B)</p> Signup and view all the answers

Flashcards

General Survey

The initial assessment that provides overall health information about a client.

Five Vital Signs

Essential indicators of health status including temperature, pulse, respiration, blood pressure, and pain level.

Overall Impression

Objective observation of a client's appearance, mobility, and physique during the general survey.

Mental Status Examination

A structured assessment evaluating cognitive and behavioral functioning of the patient.

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Components of Mental Status

Elements assessed in the mental status examination, such as consciousness, speech, mood, and thought.

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Pulse Rate

The number of times the heart beats per minute, normally 60-100 bpm for adults.

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Normal Pulse Range

The normal pulse for healthy adults ranges from 60 to 100 beats per minute.

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Pulse Variability

Pulse rate may fluctuate due to exercise, illness, injury, and emotions.

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Athletic Pulse

Athletes may have a resting heart rate near 40 bpm without problems.

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Respiratory Rate

The number of breaths taken per minute, normal rate is 12 to 16 for adults at rest.

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Systolic Pressure

The higher number in blood pressure, indicating pressure when the heart contracts.

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Diastolic Pressure

The lower number in blood pressure, indicating pressure when the heart is at rest.

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Blood Pressure Categories

Blood pressure is classified as normal, elevated, Stage 1, Stage 2, or hypertensive.

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Vital Signs

Measurements of essential body functions: temperature, pulse, respirations, and blood pressure.

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Core Temperature

Temperature of deep internal organs, such as abdomen and pelvis.

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Surface Temperature

Temperature of the skin and subcutaneous fat layers.

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Factors Affecting Body Temperature

Age, exercise, hormones, stress, environment, circadian rhythms can alter body temperature.

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Temperature Regulation

Body's mechanisms to maintain temperature: shivering, sweating, vasoconstriction.

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Temperature Assessment - Oral

Measuring temperature via mouth, using glass or digital thermometers.

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Temperature Assessment - Rectal

Measuring temperature via the rectum, usually more accurate for core temperature.

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Pulse Measurement

Detecting shock waves from heart contractions as blood travels through arteries.

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Structure of General Survey

Consists of overall impression, mental status, and vital signs.

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Mental Status Examination Components

Includes consciousness, behavior, appearance, and thought processes assessment.

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Level of Consciousness

The degree of alertness and awareness of the client.

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Behavioral Assessment

Evaluates client’s actions, mood, and perceptions during the examination.

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Factors Affecting Heat Production

Elements that influence body temperature changes such as environment, exercise, and hormones.

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Age and Temperature

Age influences body temperature, with normal variations across different life stages.

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Diurnal Variations

Circadian rhythms that affect body temperature throughout the day.

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Temperature Assessment - By Ear

Measuring temperature using a thermometer that assesses the ear drum reflecting core temperature.

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Blood Pressure Definition

The force of blood against artery walls during heartbeats.

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Systolic vs Diastolic

Systolic is pressure during heart contraction, diastolic is pressure at rest.

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Normal Respiration Rate

Normal adult respiration rate is 12 to 16 breaths per minute.

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Pulse Assessment Factors

Pulse assessment includes rate, rhythm, amplitude, contour, and elasticity.

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Fluctuating Pulse

Pulse rate can change with exercise, illness, or emotions.

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Pain as a Vital Sign

Pain is often referred to as the fifth vital sign.

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Normal Adult Pulse Range

Normal pulse for healthy adults ranges from 60 to 100 beats per minute.

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Athletic Heart Rate

Athletes can have resting heart rates near 40 beats per minute.

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Mental Status Assessment

Examination determining client's emotional and cognitive function.

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Lethargy

Client is sleepy but responds to stimuli, then falls asleep.

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Obtunded

Client responds slowly and is unaware of surroundings from loud stimuli.

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Stupor

Client can awaken with vigorous shaking but returns to sleep.

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Coma

Client remains unresponsive to all stimuli, eyes stay closed.

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Psychosocial Assessment

Evaluation of client's psychological and social well-being.

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Spiritual Assessment

Assessment of client's spiritual beliefs and needs.

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Decorticate Posture

Abnormal flexor posture indicating corticospinal tract lesions, clients draw hands to chest.

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Decerebrate Posture

Abnormal extensor posture where arms and legs extend; indicates more severe brain injury.

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Normal Posture

Client appears relaxed with shoulders and back erect when standing or sitting.

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Abnormal Posture

Slumped posture may indicate powerlessness, depression, or organic brain disease.

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Normal Grooming

Client is appropriately dressed, skin is clean, and hair/nails are neat and trimmed.

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Abnormal Grooming

Meticulous grooming or poor hygiene may indicate OCD or depression.

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Normal Facial Expression

Good eye contact and appropriate expressions such as smiles or frowns.

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Abnormal Speech

Slow, repetitive speech may indicate depression; loud, rapid speech suggests mania.

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Mental Status Assessment Components

Factors evaluated include mood, thought processes, and cognitive abilities.

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Normal Mood Findings

Client is cooperative, friendly, and expresses positive feelings about others and the future.

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Abnormal Mood Findings

Expression of worry, prolonged negative feelings, or elation and grandiosity.

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Normal Thought Processes

Client shows positive, logical thoughts and follows directions accurately.

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Abnormal Thought Processes

Includes illogical thinking, rapid flight of ideas, or suicidal ideation.

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Cognitive Abilities Assessment

Includes evaluating orientation, concentration, and memory capabilities.

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Judgement Evaluation

Assessing a client's decision-making in hypothetical situations.

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Mini-Mental Status Examination

A quick test to evaluate cognitive function and screen for cognitive loss.

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Trust vs Mistrust

Stage 1 of psychosocial development, where infants develop trust when caregivers meet their needs.

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Autonomy vs Shame and Doubt

Stage 2 of psychosocial development, focused on toddlers asserting independence and control.

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Imitative vs Guilt

Stage 3 of psychosocial development; preschoolers explore their imagination and may feel guilt for misbehavior.

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Industry vs Inferiority

Stage 4 of psychosocial development, where school-age children develop skills and relationships, facing feelings of inferiority if they struggle.

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Identity vs Role Confusion

Stage 5 of psychosocial development for adolescents, focused on forming personal identity and peer relationships.

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Erikson’s Stages

Eight stages of psychosocial development proposed by Erik Erikson, from birth to adulthood.

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Sample Interview Questions

Questions used to assess psychosocial development at different stages.

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Spirituality and Health

Religion and spirituality can improve well-being in chronic illness and end-of-life care.

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Negative Religious Views

Certain religious beliefs can hinder timely healthcare access and treatment decisions.

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FICA Tool

A spiritual assessment tool that stands for Faith, Importance, Community, Address.

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Faith Questions

Questions related to a person's beliefs and their meaning in life.

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Importance Questions

Inquiries about how beliefs influence health and self-care behaviors.

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Community Questions

Questions about one's spiritual or religious community and its support.

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Addressing Spirituality

Asking how to incorporate spirituality into healthcare discussions.

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Spiritual History Importance

Recognizing spirituality as a crucial aspect of physical and mental health.

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Intimacy vs Isolation

Developmental stage focusing on forming intimate relationships or experiencing isolation.

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Generativity vs Stagnation

Stage where middle-aged adults contribute to society or feel stagnant in life.

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Ego Integrity vs Despair

Final stage dealing with acceptance of life and readiness for mortality.

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Healthy Life Patterns

Patterns contributing to physical and emotional well-being in middle-aged adults.

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Close Relationships

Relationship quality indicating intimacy, support, and love in adulthood.

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Community Contribution

The act of contributing to society's growth and development in adulthood.

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Adjusting to Aging

Ability to adapt to physical and social changes due to aging in older adults.

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Life Reflection

Reflection on past life experiences, finding meaning and wisdom as one ages.

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Study Notes

Unit 3: Assessment of Health Status (Systematic Approach) - General Survey, Vital Signs

  • The general survey is the first step in a head-to-toe assessment
  • It provides information about the client's overall health
  • Includes:
    • Overall impression of the client (appearance, mobility, physique)
    • Mental status examination (level of consciousness, posture, body movements, appearance, behavior, attentiveness, motor and speech activity, mood and affect, thought and perception, attitude and insight)
    • Vital signs

Vital Signs

  • Temperature

    • Core temperature (deep tissues in abdominal and pelvic cavities)
    • Surface temperature (subcutaneous tissue and fat)
    • Factors affecting heat production and loss:
      • Heat production: Basal metabolism, muscular activity (shivering), thyroxine and epinephrine (metabolic rate), temperature effect on cells
      • Heat loss: Radiation, conduction/convection, evaporation
    • Regulation of temperature: Shivering (increases heat production), sweating inhibition (decreases heat loss), vasoconstriction (decreases heat loss)
    • Factors affecting body temperature: Age, diurnal variations, exercise, hormones, stress, environment
    • Normal range: 93.2 °F to 111.2 °F (34°C to 44°C). Average normal range highlighted in diagram.
    • Methods of assessment:
      • Orally (using glass or digital thermometers, including electronic probes)
      • Rectally
      • Axillary
      • Tympanically (by ear, using a special thermometer)
      • Temporally (by skin on the forehead, using a special thermometer)
  • Pulse:

    • A shock wave produced by the heart contracting and pumping blood through arteries.
    • Pulse rate is a measure of heart rate, assessed at several locations
    • Normal range for adults: 60-100 beats per minute
    • Pulse rate can fluctuate with exercise, illness, injury, and emotions
    • Females tend to have faster heart rates than males
    • Athletes can have lower heart rates
  • Respiration:

    • Respiratory rate is the number of breaths per minute
    • Respiratory rate may increase with fever, illness, and other medical conditions
    • Normal respiratory rate for adults at rest: 12-16 breaths per minute
  • Blood Pressure:

    • Force of blood pushing against artery walls during heartbeats
    • Highest pressure during contraction (systolic)
    • Lower pressure during relaxation (diastolic)
    • Measured in mm Hg
    • Normal range, elevated blood pressure, stage one, stage two, and hypertensive crisis are shown in a table format.
    • Normal range: <120/80 mm Hg
  • Pain:

    • Subjective experience that affects physical and mental health, quality of life, mood, activity, sleep, hygiene, appetite, ability to concentrate
    • Assessment includes:
      • Character, onset, location, duration, severity, pattern, associated factors.
      • Often considered as a fifth vital sign

Equipment

  • Thermometer
  • Sphygmomanometer
  • Stethoscope
  • Watch (with a second hand)
  • Alcohol swabs
  • Sheet/gown for draping

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