Module 4

Question 1

what are the 4 parts of the general survey

Answer 1

physical appearance, mental status, mobility and behaviour

Question 2

describe each component of the general survey: physical appearance

Answer 2

• Physical appearance provides immediate and important cues to the level of individual wellness
• Note any factors about client’s physical appearance that is any way unexpected
• Body should be symmetrical and proportions regular
• Nurse should consider client’s lifestyle, socioeconomic level and environment

Question 3

describe each component of the general survey: mental status

Answer 3

• Nurse assesses mental status while client is responding to questions and giving information about health history. Nurse notes client’s affect and mood, level of anxiety, orientation and speech

Question 4

describe each component of the general survey: mobility

Answer 4

• Nurse observes client’s gait, posture and range of motion. Nurse will observe deviations from the normal that include weakness, stiffness or involuntary motor activity

Question 5

describe each component of the general survey: behaviour

Answer 5

• Includes information about dress and grooming, body odours, facial expression, mood and affect, ability to make eye contact and level of anxiety. Assess the emotional state and the client for apprehension

Question 6

what are the 5 vital signs

Answer 6

• Pulse, respiration, blood pressure, temperature, oxygen saturation

Question 7

What is the normal range of temperature?

Answer 7

36-38 degrees celsius

Question 8

describe 2 mechanisms by which adults produce heat

Answer 8

• Basal Metabolic Rate (BMR): accounts for heat the body produces at absolute rest
• Shivering: an involuntary response to temperature differences in the body. Shivering increases heat production up to 5 times greater than normal.

Question 9

describe radiation

Answer 9

no direct contact (i.e. remove clothes or covers)

Question 10

describe conduction

Answer 10

direct contact (i.e. cooling sheets)

Question 11

describe convection

Answer 11

air movement (i.e. fan)

Question 12

describe evaporation

Answer 12

changes to a gas (i.e. remove clothes or covers)

Question 13

What is the normal pulse range

Answer 13

60-100 bpm

Question 14

What is the normal respiratory rate range for an adult

Answer 14

12-20 breaths/minute

Question 15

define pyrexia

Answer 15

fever; occurs when heat loss mechanisms are unable to keep pace with excess heat productions, the body temperature rises to an abnormal level

Question 16

define pyrogens

Answer 16

act as bacteria and viruses, triggering immune system responses

Question 17

define febrile

Answer 17

• WBC production is enhanced; increased temperature reduces the concentration in the blood plasma, suppressing the growth of bacteria (another word for fever)

Question 18

define afebrile

Answer 18

when the fever breaks

Question 19

define hyperthermia

Answer 19

• Body temperature that is elevated as a result of the body’s inability to promote heat loss or reduce heat production

Question 20

define heat stroke

Answer 20

• Heat depresses hypothalamic function. Conditions cause heat stroke. Dangerous heat emergency with high mortality rate

Question 21

define heat exhaustion

Answer 21

• Occurs when profuse diaphoresis results in excessive water and electrolyte loss

Question 22

define hypothermia

Answer 22

• Heat loss during prolonged exposure to the cold overwhelms the body’s ability to produce heat causing hypothermia

Question 23

define frostbite

Answer 23

• Occurs when the body is exposed to subnormal termperatures.

Question 24

define bradycardia

Answer 24

o Slow heart rate, less than 60 BPM in adults

Question 25

define tachycardia

Answer 25

o Abnormally fast heart rate, more than 100 BPM

Question 26

define pulse deficit

Answer 26

o Inefficient contraction of the heart that fails to transmit a pulse wave to pulse wave to the peripheral pulse site creates a pulse deficit

Question 27

define dysrhythmia

Answer 27

o An interval interrupted by an early or late beat or a missed beat, an abnormal rhythm

Question 28

define eupnea

Answer 28

normal respiration

Question 29

define hyperpnea

Answer 29

• Respirations are laboured, increased in depth and increased in rate. Normally occurs during exercise

Question 30

define apnea

Answer 30

• Respirations cease for several seconds

* Persistent cessations result in respiratory arrest

Question 31

define hyperventilation

Answer 31

• Rate of depth of respirations increase

Question 32

define hypoventilation

Answer 32

• Respiratory rate is abnormally low and depth and ventilation may be depressed

Question 33

define Cheyne-Stokes respirations

Answer 33

• Respiratory rate and depth are irregular, characterized by alternating periods of apnea and hyperventilation

Question 34

define Kussmaul respiration

Answer 34

• Respirations are abnormally deep, regular and increased in rate

Question 35

define Biot’s respiration

Answer 35

• Respirations are abnormally shallow for 2 or 3 breaths, followed by irregular periods of apnea.

Question 36

What is normal BP and the upper limit for healthy adult

Answer 36

12/80 mmHg, upper limit = 139/89 mmHg

Question 37

What is oxygen saturation?

Answer 37

percentage of hemoglobin that is bound with oxygen

Question 38

What is the normal range of oxygen saturation level in healthy adult

Answer 38

90-100%

Question 39

What is systolic BP?

Answer 39

pressure against artery during contraction of ventricles

Question 40

What is diastolic BP?

Answer 40

pressure against artery during ventricular relaxation

Question 41

define sphygmomanometer

Answer 41

instrument used to measure BP

Question 42

define Korotkoff sounds

Answer 42

sounds heard while auscultating a BP

Question 43

define Auscultatory gap

Answer 43

a temporary disappearance of sound