NUR 1068C Health Assessment EXAM #1 - (Chp. 1-
5,8,9,11&12) UPDATED ACTUAL Questions and CORRECT
Answers
General Survey The general survey is the first part of the physical examination that begins the
moment the nurse meets the client.
Purpose of the General Survey The outcome of the general survey provides the nurse with an overall impression
of the client’s whole being.
The general survey includes observation of the client’s:
- Physical development and body build
- Gender and sexual development
- Apparent age as compared to reported age
- Skin condition and color
- Dress and hygiene
- Posture and gait
- Level of consciousness
- Behaviors, body movements, and affect
- Facial expression
- Speech
- Vital signs
,General Routine Screening versus Focused specialty General Routine Screening (Assessment)
Assessment Generally assess the client’s level of consciousness, level of comfort, behavior,
body movements, affect, facial expression, speech, and mental acuities. If you
detect any abnormalities during your general impression examination, you will
need to do a focused speciality assessment (i.e. mental, spirutual, cardiac,
pulmonary, skin/nails etc.)
Focused Specialty Assessment
If you observe abnormalities, you may need to perform an in-depth assessment
of the body area that appears to be affected (e.g., an unusual gait may prompt
you to perform a detailed musculoskeletal assessment).
Vital signs and order Vital Signs & Order to do them in:
1st- Temperature
2nd - Pulse
3rd - Respirations
4th - Blood Pressure
Pain is no longer considered the '5th' vital sign in response to the opioid
pandemic but is still always assessed during your nursing eval.
General guidelines for proper use of equipment & how to Equipment Needed for VS:
take VS (b/p cuff, thermometers, taking pulse &
respirations) - Thermometer: tympanic, temporal, electronic oral and/or axillary or rectal
thermometers as needed.
- Protective, disposable covers for type of thermometer used
- Sphygmomanometer or Electric BP Cuff: Regular / Large / Child Size Cuff as
needed.
- Stethoscope
- Second-Hand Watch
Normal Temp. Ranges (Overall, Oral, Tympanic, Axillary, Overall Normal Range: 96.8-100.4 F (36-38 C)
Temporal, Rectal)
Oral: 96.6F-99.5F
Tympanic: 98.0°F–100.9°F Normally about 1°F higher than Oral Temp.
Axillary: 95.6°F–98.5°F Normally about 1°F lower than Oral Temp.
Temporal: 97.4°F–100.3°F Normally about 1°F higher than Oral Temp.
Rectal: 97.4°F–100.3°F Normally about 1°F higher than Oral Temp.
Pt without a fever is called: Afebrile
Normal heart rate (pulse) 60-100 beats per minute
, Normal respiratory rate 12-20 breaths per minute
normal BP range less than 120/80
abnormal vital signs / terms Anything outside of these ranges:
Heart Rate (Pulse): 60-100
High: Tachycardia >100 beats/min.
Low: Bradycardia <60 beats/min.
Blood Pressure: 120/80
Temperature: 96.8-100.4F
Below 96.8 F Hypothermia
Above 100.4 F Hyperthermia(Febrile)
Respiratory rate: 12-20 breaths/min.
<8-12 breath/min. is Bradypnea
Hypoventilation: slow, shallow breaths
>24 breath/min. is Tachypnea
Hyperventilation: rapid,deep breaths
Pulse Ox:
>95% on Room Air
Pain-5th vital sign No longer considered the 5th Vital Sign due to the opioid pandemic.
- assess pain status every time you take a full set of vital signs
- reassess (evaluate) after pain interventions
- this will stimulate patient to self-report pain
5,8,9,11&12) UPDATED ACTUAL Questions and CORRECT
Answers
General Survey The general survey is the first part of the physical examination that begins the
moment the nurse meets the client.
Purpose of the General Survey The outcome of the general survey provides the nurse with an overall impression
of the client’s whole being.
The general survey includes observation of the client’s:
- Physical development and body build
- Gender and sexual development
- Apparent age as compared to reported age
- Skin condition and color
- Dress and hygiene
- Posture and gait
- Level of consciousness
- Behaviors, body movements, and affect
- Facial expression
- Speech
- Vital signs
,General Routine Screening versus Focused specialty General Routine Screening (Assessment)
Assessment Generally assess the client’s level of consciousness, level of comfort, behavior,
body movements, affect, facial expression, speech, and mental acuities. If you
detect any abnormalities during your general impression examination, you will
need to do a focused speciality assessment (i.e. mental, spirutual, cardiac,
pulmonary, skin/nails etc.)
Focused Specialty Assessment
If you observe abnormalities, you may need to perform an in-depth assessment
of the body area that appears to be affected (e.g., an unusual gait may prompt
you to perform a detailed musculoskeletal assessment).
Vital signs and order Vital Signs & Order to do them in:
1st- Temperature
2nd - Pulse
3rd - Respirations
4th - Blood Pressure
Pain is no longer considered the '5th' vital sign in response to the opioid
pandemic but is still always assessed during your nursing eval.
General guidelines for proper use of equipment & how to Equipment Needed for VS:
take VS (b/p cuff, thermometers, taking pulse &
respirations) - Thermometer: tympanic, temporal, electronic oral and/or axillary or rectal
thermometers as needed.
- Protective, disposable covers for type of thermometer used
- Sphygmomanometer or Electric BP Cuff: Regular / Large / Child Size Cuff as
needed.
- Stethoscope
- Second-Hand Watch
Normal Temp. Ranges (Overall, Oral, Tympanic, Axillary, Overall Normal Range: 96.8-100.4 F (36-38 C)
Temporal, Rectal)
Oral: 96.6F-99.5F
Tympanic: 98.0°F–100.9°F Normally about 1°F higher than Oral Temp.
Axillary: 95.6°F–98.5°F Normally about 1°F lower than Oral Temp.
Temporal: 97.4°F–100.3°F Normally about 1°F higher than Oral Temp.
Rectal: 97.4°F–100.3°F Normally about 1°F higher than Oral Temp.
Pt without a fever is called: Afebrile
Normal heart rate (pulse) 60-100 beats per minute
, Normal respiratory rate 12-20 breaths per minute
normal BP range less than 120/80
abnormal vital signs / terms Anything outside of these ranges:
Heart Rate (Pulse): 60-100
High: Tachycardia >100 beats/min.
Low: Bradycardia <60 beats/min.
Blood Pressure: 120/80
Temperature: 96.8-100.4F
Below 96.8 F Hypothermia
Above 100.4 F Hyperthermia(Febrile)
Respiratory rate: 12-20 breaths/min.
<8-12 breath/min. is Bradypnea
Hypoventilation: slow, shallow breaths
>24 breath/min. is Tachypnea
Hyperventilation: rapid,deep breaths
Pulse Ox:
>95% on Room Air
Pain-5th vital sign No longer considered the 5th Vital Sign due to the opioid pandemic.
- assess pain status every time you take a full set of vital signs
- reassess (evaluate) after pain interventions
- this will stimulate patient to self-report pain
