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Nursing 202 > Unit 6 - General Survey, V/S, Pain Assessments > Flashcards

Unit 6 - General Survey, V/S, Pain Assessments Flashcards

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1
Q

During appraisal of the whole person, what are the four areas that you should consider?

A

Physical appearance
Body structure
Mobility
Behaviour

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2
Q

What are you assessing for in Physical appearance?

A

Age, Sex, Level of Consciousness

Skin Colour, Facial features

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3
Q

What are you assess for in Body Structure ?

A

Statues, Nutrition, Symmetry

Posture, Position, Body Build

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4
Q

What are you assessing for Mobility?

A

Gait, Range of Motion

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5
Q

What are you assessing for Behaviour?

A

Facial expression, Mood and Affect

Speech, dress, personal hygiene

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6
Q

Normal limits for Vital Signs

A 
T - 36 to 38 Degrees
P - 60 to 100 bpm
R - 12 to 20 breaths/min
BP - <120-130 / <80-85
130-139 /85-89 = high normal 
SPO2 - 92 to 100%
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7
Q

What may affect temperature?

A

Diurnal/circadian cycle,menstruation/menopause
exercise, age, environment and stress

Note: Newborns CANNOT regulate their body temp

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8
Q

What are the considerations for taking temp?

A

Assess 2 mins if pt smoked
5 mins after chewing gum
20 mins if ingested hot/cold liquids/foods

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9
Q

What does Pyrexia mean?

A

Fever, also known as febrile

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10
Q

What is Hyperthermia?

A

Increased temp

Body cannot regulate our temperature, IE: Heatstroke

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11
Q

What is Hypothermia

A

Decreased temp

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12
Q

What is Hypovolumia?

A

If the volume of our blood is low, heart rate will go up to compensate for the missing volume.

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13
Q

What may influence pulse?

A

Age, exercise, Emotions, Pain, Medications

Body positions, hypovolumia.

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14
Q

Considerations for measuring Pulse?

A

Assess by waiting 5-10 mins after activity

If irregular pulse (A-FIB - extra beat) , count for the full min.

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15
Q

What is Tachycardia?

A

Rapid pulse of beats over 100 per min

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16
Q

What is Bradycardia?

A

Slow pulse of under 60 beats per min

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17
Q

How do you assess force/strength of a pulse? (Hint: Numerical)

A

0- Absent
1+ - weak/thready
2+ - Strong/normal
3+ - Bounding

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18
Q

What may influence respirations?

A

Exercise, Pain, Anxiety, Smoking, Body positions

Medications, Brain injury, sleep

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19
Q

What is Systolic Pressure measuring?

A

Ventricular contractions

AKA how hard your heart has to push to pump to your arteries

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20
Q

What is Diastolic pressure measuring?

A

Resting, filling of the heart

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21
Q

What is mean arterial pressure?

A

Average pressure over cardiac cycle

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22
Q

What may influence blood pressure?

A

Age, Ethnocultural background, wt, emotions, gender

Diurnal rhythm, exercise, stress, medications

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23
Q

Considerations when assessing BP

A

Rest at least 5 mins (wait 60 if pt has ingested coffee or smoked)
Sit supported, feet flat on floor
Arm at level of heart, palm up

24
Q

Common errors when taking BP measurements ?

A

Inaccurate cuff size
Taking pressure when patient Is anxious, angry or has been active
Faulty technique (Arm position, failure to palpate radial)

25
Q

What is Hypotension?

A

Low Blood Pressure

26
Q

What is Hypertension?

A

High Blood Pressure

27
Q

What is Orthostatic (Postural) Hypotension?

A

Getting up to fast from a sitting to standing position.

28
Q

What are some changes in vital signs when pain is experienced?

A

Temp - Diaphoresis with acute pain (sweating)
Pulse - tachycardia with acute pain, bradycardia with unrelieved or severe pain
Resps - Shallow and increase with acute pain, irregular with severe pain
BP- Increased with acute pain, may decrease with severe pain

Patients may NOT show any changes in vital signs

29
Q

What is the 4 phases of pain (Nocioception) through the nerve pathway?

A

Transduction
Transmission
Perception
Modulation

30
Q

What is acute pain?

A

Pain that causes a sympathetic response (fight or flight), Usually lasts under 6 months
sudden pain onset, can be relieved

31
Q

what is chronic pain?

A

Last over 6 months, persistent and unrelieved pain

may case a parasympathetic response

32
Q

What is and example of Nocioceptive pain?

A

Source of pain that is a normal response

Examples are visceral pain or deep and superficial somatic pain

33
Q

What is an example of Neuropathic pain?

A

Abnormal response

Phantom Limb pain, or diabetic neuropathy

34
Q

True or False ?

Pain is whatever a patient say it is??

A

TRUE!

You can not feel there pain, therefore can not say that it does not exist. No matter what!

35
Q

The four areas to consider during the general survey are?
A) ethnicity, sex, age and socioeconomic status
B) physical appearance, sex, ethnicity and affect
C) dress, affect, nonverbal behaviour, and mobility
D) physical appearance, body structure, mobility, and behaviour

A

D) physical appearance, body structure, mobility, and behaviour

36
Q

During the general survey part of the examination, gait is assessed. When walking, the base is usually:
A) varied, depending upon the height of the person
B) equal to the length of the arm
C) as wide as the shoulder width
D) half of the height of the person

A

C) as wide as the shoulder width

37
Q

A child, 18 months of age, is brought in for a health screening visit. To assess the height of the child,
A) use a tape measure
B) use a horizontal measuring board
C) have the child stand on the upright scale
D) measure arm span to estimate height

A

B) Use a horizontal measuring board

38
Q

B.D. was delivered by Caesarean section at 38 weeks of gestation because of fetal distress. She weighed 2.8kg. This weight:
A) is appropriate for gestational age
B) is small for gestational age
C) is large for gestational age
D) cannot be determined from available data

A

A) is appropriate for gestational age

39
Q 
During the eighth and ninth decades of life, what changes occur in height and weight?
A) both increase 
B) Weight increases, height decreases
C) both decrease
D) both remain the same during the 70's
A

C) Both decrease

40
Q

During an initial home visit, the patient’s temperature is noted to be 36.6 This temperature:
A) Cannot be evaluated without a knowledge of the person’s age
B) is below normal. The person should be assessed for possible hypothermia
C) should be retaken by the rectal route because this best reflects core body temperature
D) should be reevaluated at the next visit before a decision is made

A

A) Cannot be evaluated without a knowledge of the persons age

41
Q

Select the best description of an accurate assessment of a patient’s pulse.
A) Count for 15 seconds if pulse is regular
B) begin counting with 0; count for 30 seconds
C) count for 30 seconds, and multiply by 2 for all cases
D) count for 1 full minute; begin counting with 0

A

B) Begin counting for 0; count for 30 seconds

42
Q 
After addressing the patients' pulse, the practitioner determines the pulse force to be "normal". This would be recorded as: 
A) 3+
B) 2+ 
C) 1+
D) 0
A

B) 2+

43
Q

Select the best description of an accurate assessment of a patient’s respirations
A) count for a full minute before taking the pulse
B) Count for 15 seconds and multiply by four
C) Count after informing the patient where you are in the assessment process
D) Count for 30 seconds following pulse assessment

A

D) Count for 30 seconds following pulse assessment

44
Q

Pulse pressure is:
A) the difference between the systolic and diastolic pressure
B) a reflection of the viscosity of the blood
C) another way to express the systolic pressure
D) a measure of vasoconstriction

A

A) The difference between the systolic and diastolic pressures

45
Q

The examiner is going to assess for coarctation of the aorta. In an individual with coarctation, the thigh pressure would be:
A) Higher than in the arm
B) equal to that in the arm
C) there is no constant relationship. Findings are highly individual
D) lower than in the arm

A

D) lower than in the arm

46
Q

Mean arterial pressure is:
A) The arithmetic average of systolic and diastolic pressures
B) the driving force of blood during systole
C) diastolic pressure plus one-third pulse pressure
D) corresponding to phase III Korotkoff’s

A

C) Diastolic pressure plus one-third pulse pressure

47
Q 
At what phase during nociception does the individual become aware of a painful sensation?
A) modulation
B) transductions
C) perception
D) Transmission
A

C) Perception

48
Q

While you are taking a history, the patient describes a burning, painful sensation that moves around his toes and bottoms of his feet. These symptoms are suggestive of:
A) nociceptive pain
B) neuropathic pain

A

B) Neuropathic pain

49
Q 
During the physical examination, your patient is diaphoretic and pale, and complains of pain directly over the left upper quadrant (LUQ) of the abdomen. This would be categorized as: 
A) Cutaneous pain. 
B) somatic pain 
C) visceral pain
D) Psychogenic pain
A

C) Visceral pain

50
Q

While caring for a preterm infant, you are aware that:
A) inhibitory neurotransmitters are in sufficient supply by 15 weeks gestation
B) the fetus has less capacity to feel pain
C) repetitive blood draws have minimal long-term consequences
D) the preterm infant is more sensitive to painful stimuli.

A

D) The preterm infant is more sensitive to painful stimuli

51
Q 
The most reliable indicator of pain in the adult is: 
A) degree of physical functioning 
B) nonverbal behaviours
C) magnetic resonance imaging findings 
D) the patients self report
A

D) The patients self report

52
Q 
For examining a broken arm of a 4 year old boy - select the appropriate assessment tool to evaluate his pain. 
A) 0-10 numeric rating scale 
B) Faces pain scale 
C) simple descriptor scale 
D) 0-5 numeric rating scale
A

B) Faces pain scale

53
Q

When a person presents with acute pain of the abdomen, following the initial examination, it is best to withhold analgesia until diagnostic testing is completed and a diagnosis is made.
True or false?

A

False

54
Q 
For older adults postoperative patients, poorly controlled acute pain places them at higher risk for:
A) Atelectasis
B) increased myocardial oxygen demand 
C) impaired wound healing 
D) all of the above
A

D) All of the above

55
Q 
A 30 year old female reports having persistent intense pain in her right arm related to trauma sustained from a car accident 5 months ago. She states that the slightest touch or clothing can exacerbate the pain. This report is suggestive of: 
A) referred pain
B) psychogenic pain 
C)Complex regional pain syndrome 
D) cutaneous pain
A

C) Complex regional pain syndrome

56
Q 
The PIPP is an appropriate pain assessment tool for 
A) Cognitively impaired older adults 
B) children ages 2 to 8 years. 
c) infants 
D) premature infants
A

D) Premature infants

57
Q 
A pain problem should be anticipated in a cognitively impaired older adult with a history of : 
A) diabetes 
B) peripheral vascular disease
C) COPD
D) Parkinson's disease
A

B) Peripheral vascular disease

Nursing 202 (6 decks)

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