Ch7 General Survey

The client’s physical appearance, including facial appearance, body shape and build, and apparent nourishment, provides immediate and important clues to the level of individual wellness.

When the nurse assesses the mental status of the client, the nurse is observing mood, level of anxiety, orientation, and speech.

The normal respiratory rate of adults is between 15 and 20 per minute.

Respiratory rates of 30–80 per minute are the normal range for newborns.

Respiratory rates of 20–40 per minute are considered normal for ages up to 1 year.

A respiratory rate of 8–10 per minute is abnormally slow respirations for any age group.

Tachycardia is defined as a pulse rate over 100 bpm.

A variety of behaviors indicate the presence of pain. Many of these behaviors are nonverbal such as grimacing.

The nurse would be wise to ask the client about the level of pain instead of making comments that are clearly contrary to observation such as stating that the client is moving better or assuming that the client stopped taking the pain medication.

Using the physician as a threat is not using therapeutic communication techniques.

Based on Mr. Miller’s history of hypertension, this recording is considered to be abnormal.

The pulse rate will normally increase with exercise. This client just walked down the hall as part of the prescribed physical therapy program.

A reduced heart rate might be assessed if the client was at rest.

The heart rate should be higher than the resting heart rate due to exercise.

Exercise should not produce irregularities in the rhythm of the pulse.

During the general survey of the client, the nurse will observe the client performing the following common activities: walking into the examination room, taking a seat for the interview, and moving the arms and hands to arrange clothing or to shake hands as an introduction.

The nurse observes the client’s gait, posture, and range of motion when assessing mobility in the general survey.

Physical appearance, mental status, and behavior are the other components of the general survey. Difficulty with gait and posture, such as limping, calls for further evaluation.

The bladder of the blood pressure cuff must fit the length and width of the client’s limb. A cuff that is too narrow will produce a false high reading. Conversely, if the cuff is too wide, the reading will be falsely low. If the blood pressure is low, lowering the head of the bed, or placing the client in a supine position is recommended.

Standing may further lower the blood pressure. The nurse needs to verify that this blood pressure measurement was correct and gather more assessment data before calling the physician.

Low blood pressures are not normal in the elderly. With age, blood pressure tends to rise.

Assessment of the impact of pain on ADLs enables the nurse to understand the severity of the pain and the impact of the pain on the client’s quality of life.

There is not enough information to determine whether the client takes pain medication on a “routine” basis.

Based on what the client has described as routine ADLs, the nurse can accurately document that the pain doesn’t interfere with this client’s normal activities.

There is no information that implies that the client uses work to cope with the pain or is stoic.

Discrepancies between the stated height and weight and the actual measurements may provide clues to the client’s self-image.

Not enough information is provided to determine if the client is lying, is embarrassed about their height and weight, or has not had a height and weight assessment recently.

Discrepancies in weight may also indicate the client’s lack of awareness of sudden weight change that may be due to illness.

Older adults often consume several prescription medications. Overmedication may occur because older adults seek care from multiple health care providers without collaboration regarding treatment. Multiple medications for the same condition may combine to produce dangerous side effects.

The nurse would document the medications in the medical record; however, the priority intervention is to call the physician and verify that they are aware of the situation.

Sending an order to the pharmacy and doing nothing are not appropriate.

The nurse needs more information about the prescribed medications.

The most reasonable cause for the temperature elevation is stress. The temperature of a highly stressed client may be elevated as a result of increased production of epinephrine and norepinephrine, which increase metabolic activity and heat production.

Core body temperature that is highest in the late evening and lowest in the early morning is an example of diurnal temperature variations.

Ovulation can raise body temperature by as much as 0.5°F. This question doesn’t identify the gender of the client.

There is nothing to suggest that this client had an underlying infection or illness prior to the injury.

The tympanic temperature measures a client’s core body temperature quickly and accurately. This method is the most comfortable and least invasive for the client.

Rectal temperatures are used in clients who are comatose, confused, or unable to close their mouth. However, in these situations a tympanic temperature could be used and is less invasive.

An oral temperature should not be used on this client because of the endotracheal tube and the inability to close the mouth.

The axillary temperature is the least accurate of the temperature methods and isn’t indicated since a tympanic device is available.

In adults, the diastolic pressure (Phase 5) is the point at which the sounds become inaudible.

Phase 1 sounds are the first sounds heard and signify systolic blood pressure.

Phase 3 is the period in which the sounds are louder. Phase 2 is the period during which the sounds are softer and longer.

Phase 4 is the period during which the sounds become muffled.

The client is overweight and is attempting to rationalize it by comparing herself with other family members. The fact is, the client is overweight, and the nurse needs more information on the client’s feelings about this fact before educating the client on the risks of being overweight and obtaining family history.