Upgrade to remove ads
Only $35.99/year

NCM 101 (3) General Survey, Mental Status, and Vital Signs

Terms in this set (90)

A.
The nurse is beginning a health history interview with an adult client who expresses anger at the nurse. The best approach for dealing with an angry client is for the nurse to

A. Allow the client to ventilate his or her feelings.
B. Offer reasons why the client should not feel angry.
C. Provide structure during the interview
D. Refer the client to a different health care provider
...
While interviewing an adult client about the client's stress levels and coping responses, an appropriate by the nurse

A. "Do you feel stress at work?"
B. "How often do you feel stressed?"
C. "Is stress a problem in your life?
D. "How do you manage your stress?"
...
The client's temperature at 8:00 AM using an oral electronic thermometer is 36.1°C (97.2°F). If the respiration, pulse, and blood pressure are within normal range, what would the nurse do next?

A. Wait 15 minutes and retake it.
B. Check what the client's temperature was the last time. C. Retake it using a different thermometer.
D. Chart the temperature; it is normal.
...
Which of the following clients meets the criteria for selection of the apical site for assessment of the pulse rather than a radial pulse?

A. A client is in shock
B. The pulse changes with body position changes
C. A client with an arrhythmia
D. It is less than 24 hours since a client's surgical operation
...
It would be appropriate to delegate the taking of vital signs of which of the following clients to a UAP?

A. A patient being prepared for elective facial surgery with of stable hypertension.
B. A patient receiving a blood transfusion with a history of transfusion reactions.
C. A client recently started on a new antiarrhythmic agent.
D. A patient who is admitted frequently with asthma attacks.
...
A nursing diagnosis of Ineffective Peripheral Tissue Perfusion would be validated by which one of the following:

A. Bounding radial pulse
B. Irregular apical pulse
C. Carotid pulse stronger on the left side than the right D. Absent posterior tibial and pedal pulses
C.
The nurse reports that the client has dyspnea when ambulating. The nurse is most likely to have assessed which of the following?

A. Shallow respirations
B. Wheezing
C. Shortness of breath
D. Coughing up blood
General Survey
First part of the physical examination
Use all observational skills
Provides overall impression of the client's whole being
-Endomorph
-Mesomorph
-Ectomorph
Types of body build
Endomorph
typically has short arms and legs, and has a lot of muscle on their frame, with regards to physical activity the size is a great factor and is great in sports such as rugby etc., has a round head, wide hips and shoulders
Mesomorph
excels in strength, agility and speed, their medium structure and height along with their tendency to gain muscle, has a cubicle head, a wide shoulder is common for this body type
Ectomorph
long, slender and thin and therefore power and strength is perhaps not suitable for them
Mental Status
Client's level of cognitive functioning (thinking, knowledge, problem solving) and emotional functioning (feelings, mood, behaviors, stability)
Mental Disorder (Features)
A behavioral or psychological syndrome or pattern that occurs in an individual
That reflects an underlying psychobiologic dysfunction
The consequences of which are clinically significant distress or disability
-Economic &Social
-Psychosocial developmental
-Unhealthy lifestyle
-Exposure to violence
-Personality factors
-Spiritual factors
-Cultural factors
-Changes & impairments in the structure and factors function of neurologic system
Factors Affecting Mental Health
Biographical Data
-Name, address, telephone number
-Age, Date of birth
-Marital Status
-Educational Level, employment
History of Present Health Concerns
-Urgent health concern, reason for seeking health care
-other health problems, headache, trouble breathing, heart palpitations:
Personal Health History
Hx of medical or hospitalization for a mental health problem, counseling.
-Head injury, meningitis, encephalitis, stroke -served in the armed forces
Family History
history of anxiety, depression, bipolar disorder, schizophrenia, Alzheimer's disease -treatment
ADLS, energy level
Neurologic & mental illnesses can alter one's response- to ADLS, anxious=restless, depressed=fatigued
Eating habits
Depression, eating disorder, substance abuse=poor appetite
Daily bowel elimination patterns
IBS or PUD may be associated with psychological disorders
Sleep patterns
Insomnia is often seen in depression, anxiety disorders, bipolar disorders & substance abuse
exercise regimen
Depression may be seen in those with sedentary lifestyle
caffeinated beverages
Caffeine is a psychostimulant with the potential to increase stress
Medication (prescribed or OTC).
May alter LOC, decrease response times and cause changes moods & temperament
Alcohol
May cause symptoms of forgetfulness or confusion, which could be mistaken for signs of Alzheimer's disease
Religious affiliations
Extreme, rigid practices may be a source of stress and anxiety
Self-concept
Low self-concept for depression, eating disorders & substance abuse
Relationships & Support Systems
Stressful relationships or roles may interfere with one's mental health. Provides info for referrals & possible use of community support groups.
Life Stressors
May impair one's mental health.
Suicidal thoughts and risks
Best intervention for this kind of situation: Approaching to comfort the patient, offering yourself that you want to listen and be there for the client
Vital Signs
Vital sign is the clinical measurements specifically the:
-Temperature, Pulse, Respiration, Blood Pressure and Pain
-Monitor functions of the body
-Should be a thoughtful, scientific assessment
-Metabolism
-Muscular activity
-Other factors and heat loss through the
a. Skin
b. Lungs
c. body wastes
Body Temperature Represents the balance between heat produced by:
True
T or F:

Thermoregulatory center in the hypothalamus regulates temperature
Heat Production
-Primary source is metabolism
-Hormones, muscle movements, and exercise increases metabolism
-Skin (primary source)
-Evaporation of sweat
-Warming and humidifying inspired air
-Eliminating urine and feces
Sources of Heat Loss
-Radiation
-Convection
-Evaporation
-Conduction
Transfer of Body Heat to External Environment
Radiation
The diffusion or dissemination of heat by electromagnetic waves. Ex. The body gives off waves of heat from uncovered surfaces.
Conduction
The transfer of heat to another object during direct contact. Ex. The body transfers heat to an ice pack, causing the ice to melt.
Convection
The dissemination of heat by motion between areas of unequal density. Ex. An oscillating fan blows currents of cool air across the surface of warm body
Evaporation
The conversion of liquid to a vapor. Ex. Body fluid in the form of perspiration and insensible loss is vaporized from the skin.
-Age
-Diurnal variation
-Exercise
-Hormones
-Stress
-Environment
Factors Affecting Body Temperature
-Oral
-Rectal
-Axillary
-Tympanic Membrane
-Skin/Temporal Artery
Sites for measuring body temperature
35.9-37.5°C
Normal Temperature for adults (oral)
36.3-37.9°C
Normal Temperature for adults (rectal)
35.4- 37.0°C
Normal Temperature for adults (axillary)
36.7- 38.3°C
Normal Temperature for adults (tympanic)
36.3- 37.9°C
Normal Temperature for adults (temporal)
Radial
Pulse site:
Readily accessible (commonly assessed)
Temporal
Pulse site:
When radial pulse is not accessible
Carotid
Pulse site:
During cardiac arrest/shock in adults Determine circulation to the brain (there is inequality between the pulse amplitude in the carotid artery. Never check the amplitude bilaterally
Apical
Pulse site:
Infants and children up to 3-5 years of age. Discrepancies with radial pulse. Monitor some medications. (taken when cardiovascular assessment or client that takes a cardiovascular medication)
Brachial
Pulse site:
Blood pressure Cardiac arrest in infants (commonly used in assessing the blood pressure of your client)
Femoral
Pulse site:
Cardiac arrest/shock (most sensitive in assessing for septic shock, it is checked during resuscitation)
Popliteal
Pulse site:
Circulation to lower leg
Posterior tibial
Pulse site:
Circulation to the foot (difficult to palpate)
Dorsalis pedis
Pulse site:
Circulation to the foot (10% of the general population doesn't have this because of the anatomical variation) CHARACTERISTICS OF THE PULS
Rate
Is the speed of the beat measured by the number of contractions of the heart per minute.
Rhythm
A regular or rhythmical beating. Meaning that the frequency of the pulsation felt by your fingers follows an even tempo with equal intervals between pulsation.
Volume
Pulse force four-point scale
Pulsus alternans
rhythm is normal/regular but the volume has alterations and it has a weak character. (client is having left ventricular failure/the heart block)
Bigeminal pulse
rregular rhythm in which every other beat comes weak. (this suggests myocardial infarction)
Collapsing/ water hammer pulse
a full volume pulse but rapidly collapsing pulse occurring in aortic regurgitation.
Paradoxical pulse
the force/strength of the pulse way(?) varies weaker during inspiration.
True
T or F: most accurate assessment of pulse rate is apical pulse
Respiration
Interchange of gases between an organism and the medium in which it lives.
External respiration
- is the exchange of 02 and CO2 between the atmosphere and the body.
Internal respiration
takes place throughout the body at the cellular level
Exercise
there is an increase of muscle activity and muscle cells respire more than they do when the muscle at rest. The rate of breathing increases. This is to ensure that more oxygen comes to the blood and more carbon dioxide is released.
Stress
it makes your breathing harder. In addition, stress can lead to hyperventilation.
Environmental temperature
when exercising in a cold temperature, it could be hard time for those people who people who had previous lung and breathing problems.
Medications
some medicines could cause to the patient a hard time breathing and in their respirations.
Rate
number of breaths you take per minute
Eupnea
meaning normal rate, 12-20
Bradypnea
abnormal rate, less than 12
Tachypnea
abnormal, more than 20
Depth
amount of air that is inhaled and exhaled
Rhythm
includes the entire inhaling and breathing pattern
Inspection
this can be used to appreciate the level of distress of the patient using your senses
Listening with stethoscope
can listen to the normal and abnormal respirations of the patients
monitoring arterial blood gas results
- the standard for monitoring gas oxygenation
using a pulse oximeter
measures your oxygen saturation, the oxygen level in your blood
Systolic
Contraction of the ventricles
Diastolic
-Ventricles are at rest
-Lower pressure present at all times
Phase 1
Korotkoff's Sounds:
-First faint, clear tapping or thumping sounds
-Systolic pressure
-First sound heard as the cuff pressure is released this sound provides the systolic pressure rhythm
Phase 2
Muffled, whooshing, or swishing sound as the blood flows through the blood vessels as the cuff is deflated
Phase 3
-Blood flows freely
-Crisper and more intense sound Thumping quality but softer than in phase 1 is the blood flows through the artery but the cuff pressure is still inflated to occlude flow during diastole
Phase 4
Muffled and have a soft, blowing sound as the cuff pressure is released the change from thump of phase 3 from the muffled sound of phase 4 is known as the first diastole beating
Phase 5
-Pressure level when the last sound is heard, Period of silence
-Diastolic pressure
Sets found in the same folder