Nursing Assessment: General Survey and Temperature

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

<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

<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

<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

<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

<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

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

<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

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

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

<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

<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

<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

<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

<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

<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

<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

<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

<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

<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

<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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

<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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Temperature of the skin and subcutaneous fat layers.

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

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

Measuring temperature via mouth, using glass or digital thermometers.

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

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

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

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

The degree of alertness and awareness of the client.

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

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

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

Circadian rhythms that affect body temperature throughout the day.

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

The force of blood against artery walls during heartbeats.

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

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

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

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

Pain is often referred to as the fifth vital sign.

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

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

Examination determining client's emotional and cognitive function.

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

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

Client can awaken with vigorous shaking but returns to sleep.

Client remains unresponsive to all stimuli, eyes stay closed.

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

Assessment of client's spiritual beliefs and needs.

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

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

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

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

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

Meticulous grooming or poor hygiene may indicate OCD or depression.

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

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

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

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

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

Client shows positive, logical thoughts and follows directions accurately.

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

Includes evaluating orientation, concentration, and memory capabilities.

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

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

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

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

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

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

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

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

Questions used to assess psychosocial development at different stages.

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

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

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

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

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

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

Asking how to incorporate spirituality into healthcare discussions.

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

Developmental stage focusing on forming intimate relationships or experiencing isolation.

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

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

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

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

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

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

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