General Survey
What is appearance?
Component of general survey that includes hygiene, dress, and apparent age.
Normal adult temperature range
36.5-37.4 C
97.7-99.5 F
Normal adult pulse range
What is 60-100 beats per minute
"Normal" adult blood pressure
What is less than 120/80 mm Hg
What does O stand for in OLDCARTS?
What is onset
gait, posture, and ease of movement
This route is often preferred for quick screening in children.
Temporal or tympanic temperature
3 characteristics of pulse assessment
What is rate, rhythm, and amplitude.
This sound is heard when measuring blood pressure manually
This pain scale is commonly used for alert adults who can communicate.
What is the numerical rating scale
appears anxious
eye contact
A patient has consumed hot coffee 5 minutes before an oral temperature is obtained. How may this affect the reading?
The temperature may be falsely elevated.
Tachycardia
The patient's legs are crossed while BP is measured. How could this affect the reading?
May falsely increase blood pressure
A patient rates pain 8/10 but is smiling and talking with family. Should the nurse discount the pain rating?
No. Self-report is the gold standard of pain assessment.
Two factors that can influence a nurse's impression during general inspection.
culture, personal biases, environment, stereotypes, previous experiences, communication barriers.
An oral temperature is reported at 101.3 F. What term describes this finding?
Fever (pyrexia)
The nurse counts 28 respirations per minute. How would this respiratory rate be documented?
Tachypnea
A student's manual blood pressure is 140/90 mm Hg. The patient was talking during obtainment of blood pressure. What should the nurse do?
Allow rest and repeat the BP using proper technique
A patient with advanced dementia cannot verbalize pain. What assessment tool should the nurse consider?
PAINAD
A patient enters the clinic leaning on the wall, appears pale and diaphoretic, and is breathing rapidly. What concerning findings should the nurse recognize and assess?
instability
vital signs
pain
level of consciousness
A confused older adult receiving oxygen by mask needs their temperature assessed. What route would be most appropriate and why?
Tympanic or temporal because oral may be inaccurate or difficult.
The patient has shallow respirations of 10 breaths/minute. Which nursing action should occur first?
Assess respiratory status further, notify the provider
The patient's SpO2 is 88% on room air, and the patient appears short of breath. What should the nurse consider?
Assess respiratory effort, airway, oxygen needs, and provider notification
Two patients with the same surgery report different pain levels. What factors might explain the difference?
Culture, previous experiences, anxiety, coping abilities, beliefs, expectations, support systems, and pain tolerance