Chapter 10

Question 1

Introduction

Answer 1

Vision
Hearing
Smell

Question 2

Components of the General Survey

Answer 2

Physical appearance
Mental status
Mobility
Behavior
Lifespan considerations
Patient's ability to participate

Question 3

Physical Appearance

Answer 3

Body shape
Build
Height and weight
Compared to stated age
Assessment of function and symmetry

Question 4

Mental Status

Answer 4

Orientation
Affect: in pain? Hiding?
Anxiety: shaking, crying

Question 5

Mobility

Answer 5

Posture: Shoulders straight and level
Gait: Walk; Rhythmic
Range of motion

Question 6

Measuring weight and height

Answer 6

Large discrepancies between stated height and weight and actual measurements may provide clues to patient’s self-image

Question 7

Lifespan Considerations

Answer 7

Infants
Measure length
Place on standard examination table with legs extended and mark on paper below

Children able to stand on their own at full height should be measured in a standing position.
Children age 2 or 3 may be weighed on upright scale or seated on the infant scale.

Question 8

Measuring Vital Signs

Answer 8

Obtain baseline data
Detect of monitor a change
Monitor patients at risk for alterations in health

Includes: Temperature, Pulse, Respiratory rate
Blood pressure, Pain, Oxygen saturation

Question 9

Measuring Body Temperature

Answer 9

Surface temperature unreliable because it fluctuates in response to environmental factors
Relatively constant temperature of body tissues at 37°C or 98.6°F

Factors include: Age, Diurnal variations, Exercise, Hormones, Stress

Question 10

Ways to measure body temperature

Answer 10

Oral: Most accessible, accurate method
Rectal
Axillary (armpit)
Tympanic (ear)
Temporal Artery

Question 11

Measuring the Pulse Rate

Answer 11

Stroke volume: Amount of blood pumped from heart with each heartbeat
Compliance: Ability of the arteries to contract and expand

Location of the pulse points
Apical (left side): Apex of the heart. 5th intercostal

Peripheral
For example, neck, wrist, or foot
Can be weakened by alterations in patient’s health

Females have higher pulses, hemorrhaging increases pulse

Question 12

Bradycardia

Answer 12

Pulse of less than 60 beats/min

Question 13

Tachycardia

Answer 13

Pulse over 100 beats/min
Normal artery feels smooth, straight, and resilient.
Thready or bounding pulses can indicate health alterations.

Question 14

Oxygen saturation

Answer 14

Measured using a pulse oximeter
In a healthy individual, 97% to 99% considered normal
If 90% or below, investigate

Question 15

Systolic

Answer 15

Pressure during left ventricular contraction

Question 16

Diastolic

Answer 16

Pressure during the “resting” period of the heart

Question 17

Measuring Blood Pressure

Answer 17

Factors that influence BP: 
Cardiac output
Blood volume
Peripheral vascular resistance
Blood viscosity
Vessel compliance
Stress
Diurnal variations: day and night variations

Question 18

Assessment of blood pressure

Answer 18

Patient should rest for at least 5 minutes prior, or 20 minutes if engaging in heavy physical activity.

Confirm that blood pressure cuff is appropriate size for patient’s arm
Remove any clothing from patient’s arm
Slightly flex arm and hold it at the level of the heart with the palm upward
Palpate brachial pulse
Place cuff on arm with lower border 1 inch above antecubital area
Palpate radial pulse
Close release valve on pump
Inflate cuff until radial pulse no longer palpable
Place diaphragm of stethoscope over brachial pulse
Pump cuff until sphygmomanometer registers 30 mmHg above palpatory systolic blood pressure
Release valve on cuff carefully

Question 19

Pain—The Fifth Vital Sign

Answer 19

Subjective and personal experience

Types: Acute, Chronic, Range from severe to mild