Thermometers used to measure fevers will not detect as thermometers

SECTION IV: DOCUMENTATION

G. Thermometers used to measure fevers will not detect as thermometers

SECTION I: LEARNING OBJECTIVES

Learning Objectives The student will:

Identify the components of the general survey.

Identify appropriate subjective questions based on initial observations.

Demonstrate how to measure blood pressure, pulse, respiration, and temperature.

Discuss variations in vital signs and the pos- sible causes.

Describe the different types of pain.

Perform and document a pain assessment uti- lizing information from the health history and the physical examination.

SECTION II: STUDY GUIDE

Activity A FILL IN THE BLANK 1.

Complete the following statements:

List the components of a general survey.

Activity B MATCHING

Match the description of the blood pressure cuff error with the type of error (type of error will have multiple descriptions).

Answer Description of Error Type of Error Cuff too small (narrow) A. False low readings Cuff too large (wide) B. False high readings Pressing stethoscope too tightly

against pulse

Infl ating or defl ating cuff too slowly Cuff too loose or uneven

Repeating assessments too quickly Defl ating cuff too quickly

Match the special technique with the problem obtaining an accurate blood pressure.

Answer Special Technique Problem

Doppler ultrasound stethoscope A. Apical pulse should be taken Radial pulse is diffi cult to fi nd or

there is an irregularity

B. Hypertension in people whose blood pressure measurements are higher in the offi ce than at home or in more relaxed settings Weak or inaudible Korotkoff sounds C. The obese arm

Frequent premature contractions or atrial fi brillation

D. Atrial fi brillation

Important to use a wide cuff of 15 cm E. Weak pulse

“White coat hypertension” F. Consider technical problems Palpation of an irregular rhythm G. Determine the average of several

observations and note that your measurements are approximate

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CHAPTER 7 BEGINNING THE PHYSICAL EXAMINATION: GENERAL SURVEY, VITAL SIGNS, AND PAIN 29

Match the defi nition to its corresponding description.

Answer Defi nition Description

Night sweats A. Can be used with unconscious patients

Sweating B. Measures core body temperature

Axillary temperatures C. Accompanies a rising temperature

Feeling cold D. Usually blue

Tympanic membrane temperature E. Usually red

Rectal thermometer F. Accompanies a falling temperature Oral thermometer G. Occur in tuberculosis and malignancy

12.

Mr. Smith presents to the clinic stating, “My face looks funny.” You note that his face is asymmetric. What might you suspect is the patient’s problem?

Heart attack

Parafacial macrosomia

Muscular dystrophy

Palsy

13.

Mrs. Helms is admitted to your unit with an exacerbation of COPD. When you enter her room to do your initial assessment, you note that she is sitting on the side of the bed, leaning forward, with her arms on the bed- side table. What would this indicate to you?

Respiratory distress

A relaxed attitude

Depression

Pulmonary embolism

14.

A patient admitted to your unit from the emergency room is noted to have “grown- out” nail polish. What might this indicate?

Inability to give accurate history

Depression

Length of an illness

Inability to perform ADLs

15.

As a nursing student you learn that the nor- mal range for an adult pulse is what?

80–120 bpm

70–110 bpm

60–100 bpm

50–90 bpm

Activity C SHORT ANSWER

Discuss the measuring of the severity of pain.

Discuss the health disparities in pain manage- ment.

Compare and contrast the different types of pain.

10.

Discuss health promotion as it pertains to the general survey.

Activity D NCLEX STYLE QUESTIONS 11.

What factors contribute to the patient’s

makeup? (Mark all that apply.)

Ethnicity of patient

Nutrition

Genetic composition

Geographic location

Cultural norms

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16.

Fatigue is considered a common symptom of what? (Mark all that apply.)

Infections

Panhypopituitarism

Mild anemia

Depression

Hyperthyroidism

17.

You are educating your patient on taking blood pressure at home. What would be important to include in your patient education?

Monthly replacement of batteries

Routine recalibration of the device

Application of a thigh cuff

Use of a wrist cuff

18.

Ideally, when taking a blood pressure, the patient should be instructed to what?

Avoid smoking for 30 minutes prior to the assessment

Sit quietly for at least 10 minutes in a chair, rather than on the examining table, with feet fl at on the fl oor and legs uncrossed

Abstain from drinking caffeine for 45 min-

utes prior to the assessment

Take several deep breaths to help relax prior to the assessment

19.

The nurse should know that some disease processes affect facial expression. What are they? (Mark all that apply.)

Diabetes mellitus

Depression

Multiple sclerosis

Parkinsonism

Hyperthyroidism

20.

When counting the patient’s pulse, what beats may not be detected peripherally?

Split beats

Early beats

Irregular beats

Late beats

SECTION III: CASE STUDY

Activity E

Ms. Cox has come to the clinic with a chief com- plaint of “severe sore throat.” She is 27 years old, is married, and has one child. She is dressed in jeans and a light sweater.

Document a general survey for this patient.

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SECTION I: LEARNING OBJECTIVES

Learning Objectives The student will:

Assess the nutritional status of an individual through a nutrition history and physical examination.

Identify persons at risk for malnutrition or overnutrition.

Differentiate between normal and abnormal nutrition assessment fi ndings.

SECTION II: STUDY GUIDE

Activity A FILL IN THE BLANK 1.

Complete the following statements:

Dalam dokumen Student Laboratory Manual for Bates’ Nursing Guide to Physical Examination and History Taking (Halaman 35-39)