Ch 09: General Survey, measurements, vital signs

Question 1

study of the whole person that includes observing the patient’s physical appearance, body structure, mobility, and behavior
ex:Observing the patient’s body stature and nutritional status

Answer 1

General Survey

Question 2

used to measure weight

Answer 2

standardized balance scale

Question 3

If a sequence of repeated weights is necessary,

Answer 3

then the nurse should attempt to weigh the patient at approximately the same time of day and with the same types of clothing worn each time.

Question 4

systolic 120-139

diastolic 80-89

Answer 4

prehypertension

Question 5

systolic 140-159

diastolic 90-99

Answer 5

stage 1 HTN

Question 6

systolic > 160

diastolic >100

Answer 6

Stage 2 htn

Question 7

systolic >180

diastolic >120

Answer 7

Hypertensive emergency

Question 8

newborn’s head measures

Answer 8

32 to 38 cm and is approximately 2 cm larger than the chest circumference. Between 6 months and 2 years, both measurements are approximately the same, and after age 2 years, the chest circumference is greater than the head circumference.

Question 9

more prominent bony landmarks, decreased body weight (especially in men), a decrease in subcutaneous fat from the face and periphery, and additional fat deposited on the abdomen and hips. Postural changes of kyphosis and slight flexion in the knees and hips also occur.

Answer 9

Changes that occur in the aging person

Question 10

Rectal temperatures

Answer 10

taken when the other routes are impractical, such as for comatose or confused persons, for those in shock, or for those who cannot close the mouth because of breathing or oxygen tubes, a wired mandible, or other facial dysfunctions.

Question 11

both the systolic and diastolic pressures increase. (widening pulse pressure)

Answer 11

older adult

Question 12

hypothalamus regulates heat production

Answer 12

from metabolism, exercise, food digestion, and external factors

Question 13

hypothalamus heat loss (cold) thru what

Answer 13

through radiation, evaporation of sweat, convection, and conduction

Question 14

Normal temperature is influenced by?

Answer 14

diurnal cycle, exercise, and age(36.2° C (97.2° F) via the oral route.), menstruation cycle in women

Question 15

may be a sign of a short-term illness or a chronic illness such as endocrine disease, malignancy, depression, anorexia nervosa, or bulimia.

Answer 15

unexplained weight loss

Question 16

is commonly found in children and young adults. During the respiratory cycle, the heart rate varies, speeding up at the peak of inspiration and slowing to normal with expiration.

Answer 16

Sinus arrhythmia

Question 17

the force, or strength, of a pulse,

Answer 17

stroke volume

Question 18

level of blood pressure is determined by five factors

Answer 18

cardiac output, peripheral vascular resistance, volume of circulating blood, viscosity, and elasticity of the vessel walls

Question 19

order of infant vs

Answer 19

respiration, pulse, and temperature.

Question 20

decrease in vital capacity and decreased inspiratory reserve volume. The examiner may notice a shallower inspiratory phase and an increased respiratory rate

Answer 20

Aging

Question 21

Overgrowth of bone in the face, head, hands, and feet

excessive secretion of growth hormone in adulthood

Answer 21

acromegaly

Question 22

the patient’s arm span (fingertip to fingertip) should equal the patient’s height

Answer 22

during general survey

Question 23

arm span that is greater than the person’s height may indicate

Answer 23

Marfan syndrome

Question 24

falsely low systolic or falsely high diastolic reading may result, which is common in patients with hypertension

Answer 24

auscultatory gap is undetected

Question 25

the pressure forcing blood into the tissues, averaged over the cardiac cycle

Answer 25

MAP (mean arterial pressure)

Question 26

taken when the person is hypertensive or is taking antihypertensive medications, when the person reports fainting or syncope, or when volume depletion is suspected. The blood pressure and pulse readings are recorded in the supine, sitting, and standing positions

Answer 26

Orthostatic vital signs

Question 27

genetic disorder resulting in characteristic deformities;

Answer 27

Achondroplastic dwarfism

Question 28

caused by a deficiency in growth hormone in childhood and results in a retardation of growth below the third percentile, delayed puberty

Answer 28

Hypopituitary dwarfism

Question 29

is an inherited connective tissue disorder characterized by a tall, thin stature and other features

Answer 29

Marfan syndrome

Question 30

BP cuff

Answer 30

The width of the rubber bladder should equal 40% of the circumference of the person’s arm. The length of the bladder should equal 80% of this circumferenc

Question 31

characterized by weight gain and edema with central trunk and cervical obesity (buffalo hump) and round plethoric face (moon face).

Answer 31

Cushing syndrome is

Question 32

temperature, respiratory rate, pulse, and blood pressure

Answer 32

adult vs

Question 33

Shake a glass thermometer down to 35.5° C (96° F) and place it at the base of the tongue in either of the posterior sublingual pockets—not in front of the tongue. Instruct the person to keep his or her lips closed. Leave in place 3 to 4 minutes if the person is afebrile and up to 8 minutes if febrile. (Take other vital signs during this time.) Wait 15 minutes if the person has just taken hot or iced liquids and 2 minutes if he or she has just smoked.

Answer 33

Glass thermometer via oral

Question 34

advantages of swift and accurate measurement (usually less than 20 to 30 seconds)

Answer 34

electronic thermometer (can be oral or rectum)

Question 35

is used by sliding the probe across the forehead and behind the ear. The thermometer works by taking multiple readings and providing an average. The reading takes approximately 6 seconds. This approach is well tolerated and is more accurate than TMTs

Answer 35

temporal artery thermometer (TAT)

Question 36

is a noninvasive, nontraumatic device that is extremely quick and efficient. The probe tip has the shape of an otoscope
senses infrared emissions of the tympanic membrane (eardrum). The tympanic membrane shares the same vascular supply that perfuses the hypothalamus

Answer 36

(TMT)- tympanic membrane thermometer

Question 37

BP varies

Answer 37

age, sex, race, diurnal rhythm, weight, exercise, emotion, stress

Question 38

Taking blood pressure reading when person is anxious or angry or has just been active

Answer 38

Falsely high

Question 39

Faulty arm position

Above level of heart

Answer 39

Falsely low

Question 40

Below level of heart

Answer 40

Falsely high

Question 41

Person supports own arm

Answer 41

Falsely high diastolic

Question 42

Faulty leg position (e.g., person’s legs are crossed)

Answer 42

Falsely high systolic and diastoli

Question 43

Cuff too narrow for extremity

Answer 43

Falsely high

Question 44

Cuff wrap is too loose or uneven, or bladder balloons out of wrap

Answer 44

Falsely high

Question 45

Inflating cuff not high enough

Answer 45

Falsely low systolic

Question 46

Falsely low systolic

Answer 46

Falsely low diastolic

Question 47

deflating cuff Too quickly

Answer 47

Falsely low systolic or falsely high diastolic

Question 48

deflating cuff Too slowly

Answer 48

Falsely high diastolic

Question 49

Failure to wait 1-2 min before repeating entire reading

Answer 49

Falsely high diastolic

Question 50

Halting during descent and reinflating cuff to recheck systolic

Answer 50

Falsely high diastolic