Holistic Nursing Assessment

Question 1

the first part of the physical examination
that begins the moment the nurse meets
the client.

Answer 1

General Survey

Question 2

are the body’s indicators of health

also known as “cardinal signs”

Answer 2

VITAL SIGNS

Question 3

rate of energy utilization in the body

required to maintain essential activities

Answer 3

Basal Metabolic Rate (BMR)

Question 4

increases metabolic rate
using large muscles to make heat rather
than movement

Answer 4

Muscle Activity

Question 5

plays an important role on the
maintenance of core body temperature
through thermoregulation processes.

Answer 5

Sympathetic Nervous System

Question 6

transfer of heat from one molecule to a

molecule of lower temperature

Answer 6

Conduction

Question 7

transfer of heat in the form of waves

and particles

Answer 7

Radiation

Question 8

it is the dispersion of heat by air

currents

Answer 8

Convection

Question 9

it is a continuous evaporation of
molecules from the respiratory tract and
from the mucosa of the mouth and from
the skin.

Answer 9

Vaporization/Evaporation

Question 10

alternative at regular intervals between
periods of fever and periods of
normal/subnormal temperature

Answer 10

Intermittent

Question 11

wide range of temperature fluctuations

of which are above normal

Answer 11

Remittent

Question 12

short febrile periods of a few days are
interspersed with periods of 1 or 2 days
of normal temperature.

Answer 12

Relapsing

Question 13

fluctuates minimally but always remain

above normal

Answer 13

Constant

Question 14

a shock wave produced by the
contraction of the heart and forceful
pumping of blood out of the ventricles
into aorta

Answer 14

PULSE

Question 15

condition in which the apical pulse rate is

greater that the radial pulse rate

Answer 15

Pulse Deficit

Question 16

is the regularity of the heartbeat
there are regular intervals between
beats

Answer 16

Pulse Rhythm

Question 17

arrhythmia

irregular heartbeat

Answer 17

Dysrhythmia

Question 18

is a measurement of the strength or
amplitude of force exerted by the
ejected blood against the arterial wall
with each contraction.

Answer 18

Pulse Volume

Question 19

artery feels straight, resilient, & springy

Answer 19

Arterial Elasticity

Question 20

is a heart rate less than 60 bpm in an

adult

Answer 20

Bradycardia

Question 21

is a heart rate in excess of 100 bpm in

adult

Answer 21

Tachycardia

Question 22

the act of breathing
rate and character are additional clues to
the clients overall health status

Answer 22

RESPIRATIONS

Question 23

overexpansion of the lungs, rapid deep

breaths

Answer 23

Hyperventilation

Question 24

shrill harsh sound during inspiration -

laryngeal obstruction

Answer 24

Stridor

Question 25

snoring or sonorous respiration - partial | obstruction of upper airway

Answer 25

Stertor

Question 26

high pitched musical squeak on expiration - narrowed/partially obstructed airway (asthma)

Answer 26

Wheeze

Question 27

It is the measure of pressure exerted as | blood flows through the artery

Answer 27

BLOOD PRESSURE

Question 28

``` refers to client's level of cognitive functioning (thinking, knowledge, problem solving) and emotional functioning ( feelings, mood, behaviors, stability) ```

Answer 28

MENTAL STATUS

Question 29

``` an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. ```

Answer 29

PAIN

Question 30

perceived at the source of the pain | and extends to the nearby tissues

Answer 30

Radiating Pain

Question 31

felt in a part of the body that is considerably removed or far from the tissues causing the pain

Answer 31

Referred Pain

Question 32

a pain that contributes insomnia, | weight gain, constipation, etc.

Answer 32

Persistent Pain

Question 33

an emergency situation deserving | attention and professional treatment

Answer 33

Severe Pain

Question 34

excessive sensitivity to pain

Answer 34

Hyperalgesia

Question 35

the amount of pain stimulation a person requires before feeling pain least level of pain that the patient is able to detect

Answer 35

Pain Threshold/Sensation

Question 36

maximum amount and duration of pain that an individual is willing to endure

Answer 36

Pain Tolerance

Question 37

the point which the person becomes | aware of the pain

Answer 37

Pain Perception

Question 38

pain due to a stimulus that does not | normally provoke pain

Answer 38

Allodynia

Question 39

unpleasant abnormal sensation, imitates the pathology of central neuropathic pain disorder.

Answer 39

Dysesthesia

Question 40

pain directly related to tissue damage | and may be somatic

Answer 40

Nociceptive Pain

Question 41

an increased sensitivity of a receptor after repeated activation by noxious stimuli or nociceptor

Answer 41

Sensitization