N202 Exam 1

  1. What are the 5 key measurements of the general survey?
    • Height
    • Weight
    • BP
    • TPR (temperature, pulse, respirations)
    • Pain
  2. What are some of the aspects of a client's physical appearance that you should account for?
    • Age
    • Sexual characteristics
    • Skin
    • Facial features/symmetry
    • Signs of distress
    • personal hygiene
  3. Cachexia
    Low body mass
  4. Important things to recognize in general body structure
    • Stature - proper height to weight ratio
    • Nutrition - well nourished, overweight, obese, thin, cachexia
    • Symmetry - atrophy, hypertrophy, edema
    • Posture - erect, slumped
    • Build and contour - lean, muscular
    • Deformities
  5. Two categories related to mobility:
    • Gait
    • ROM
  6. What do we compare clinical measurements to?
    • Normal ranges - BP, rate and rhythm, BMI - these are also relative to: age, gender, lifestyle, etc.
    • Client's recent values or serial readings
    • Diagnosis - weight, atrophy, and other characteristics may be affected by disease or illness
  7. What is one reason for performing serial weights?
    Heart failure patients
  8. What time would you perform serial weight measurements?
    At the same time each day; normal weight changes approx. 2-3lbs per day
  9. What are some of the reasons for weight gain?
    • Overeating or inactivity
    • Fluid volume excess
    • Hypothyroidism (decreases metabolism)
    • Drug therapy (corticosteroids)
    • Diabetes
  10. 1 Liter of fluid increase will result in how many pounds?
    2.2lbs = 1 Liter of fluid volume
  11. A client has a weight increase of 6 lbs in the last 2 weeks. What may be a cause?
    • Heart failure/decompensation
    • A weight gain of 2-3 lbs per week is significant
  12. What are some reasons for weight loss?
    • Anorexia or decreased intake
    • Dehydration
    • Increased metabolic rate
    • Diabetes (new onset or poor control)
    • Malignancy
  13. What are the 4 major vital signs?
    • TPR - temperature, pulse, respiration
    • BP - blood pressure

    Pain is considered the 5th
  14. What part of the brain regulates temperature?
  15. Febrile?

    Has fever

    No fever
  16. What factors affect body temperature?
    • Diurnal cycle (1-1.5' F change with peak at 4pm and trough at 4am)
    • Menstrual cycle (1' F increase due to progesterone secretion)
    • Exercise (moderate to heavy)
    • Age (children's temperatures may run high, older adults are more at risk)
    • Illness
    • Exposure
  17. What is the normal oral temperature?
    • Oral: 98.6' F (96.4-99.1) or 37' C (35.8-37.3)
    • Rectal: +1' F or 0.5' C
    • Tympanic: +1' F or 0.5' C
    • Axillary: -1' F or 0.5' C
  18. At what age would you obtain oral temperature in children?
    5-6 years old
  19. What is the definition of fever?
    Temperature > 101' F or 38' C
  20. How long does smoking affect oral temperature?
    Hot or cold fluids?
    • Wait 2 minutes after smoking and
    • wait 15 minutes after hot/cold fluids before taking temperature orally.
  21. What route would you use with a BLUE tipped thermometer?
    • BLUE tips are for ORAL temps
  22. How long do you time the pulse rate of a regular rhythym?
    An irregular rhythym?
    • 30 seconds for a regular rate
    • 1 minute for an irregular rate/rhythym
  23. Your client's pulse rate increases with inspiration and decreases with expiration. What could this signify?
    Sinus arrythmia (common in children and young adults)
  24. Where would you palpate the pulse on a child younger than 2 years old?
    Apical pulse
  25. What is the normal heart rate in adults?
    • Normal: 60-100 beats per minute
    • Brady: <60 bpm
    • Tachy: >100 bpm
  26. What factors can increase pulse rate?
    • Age (higher in children)
    • Female
    • Exercise
    • Anxiety
    • Pain
    • Fever (higher fever, higher rate)
    • Dehydration
    • Anemia (decreased RBC/dehydration, increased rate)
  27. What is a pulse deficit?
    The difference between the apical and radial pulse rate
  28. Your patient has a radial pulse rate higher than the radial rate. What could this signify?
    Sign of Heart Disease
  29. How is pulse strength measured?
    • 4+ Bounding (at rest sign of Heart Disease)
    • 3+ Full (normal with exercise)
    • 2+ Normal
    • 1+ Weak, thready
    • 0 Absent
  30. How long do you count respirations with a normal rhythym?
    How long with an abnormal bretahing pattern?
    • Normal: count for 30 seconds
    • Abnormal: count for 1 minute
  31. What is the normal respiratory rate in adults?
    • Normal: 10-20 breaths per minute
    • Brady: <10 breaths pm
    • Tachy: >20 breaths pm
  32. What are the 5 things to assess in examining repirations?
    • Rhythym
    • Rate
    • Depth
    • Character (thoracic in women, abdominal in men and children)
    • Abnormal patterns (hyperventilation, hypoventilation, apnea, dyspnea)
  33. Blood Pressure
    Force exerted on vessel walls during cardiac cycle
  34. Systolic pressure
    Force exerted on Arterial walls during Systole
  35. Diastolic pressure
    Resting pressure during diastole
  36. Pulse pressure
    Difference between the systolic and diastolic pressures
  37. Mean arterial pressure
    • Average amount of pressure forcing blood into the tissues throughout the cardiac cycle
    • Measured: MAP = Diastolic BP + 1/3 Pulse Pressure
  38. Your client has a resting BP of 110/75
    What is the pulse pressure?
    What is the MAP (mean arterial pressure)
    • Pulse pressure = 110-75 = 35
    • MAP = 75 + 1/3(35) = 87
  39. WHat factors determine BP?
    • Cardiac output
    • Volume
    • Blood viscosity (thickness increased by: polycythemia, altitude, chronic lung disease)
    • PVR (Peripheral Vascular Resistance) - constricted vessels
    • Sympathetic nervous system stimulation - SNS causes vasoconstriction
    • Elasticity of vessels (arteriosclerosis)
  40. What is a normal BP?
    <120 systolic / <80 diastolic
  41. What blood pressure range would be considered pre hypertensive?
    • Pre-hypertensive: Systolic: 120-139 Diastolic: 80-89
    • Hypertensive*: Systolic >139 Diastolic >89

    *BP checked in both arms. Must be documented 2 times for diagnosis.
  42. Is HTN a nursing or medical diagnosis?
    Medical (the nurse would document elevated BP)
  43. What is the goal BP of diabetics?
    <130 / 80
  44. What factors increasee blood pressure?
    • Age
    • Gender (men, females post menopause)
    • Race (african americans)
    • Diurnal rhythym (higehr late afternoon, lower am)
    • Obesity
    • Exercise
    • Emotions, stress, pain (stimulated SNS)
    • Smoking (wait 30 minutes before checking BP)
    • Alcohol
    • Meds (NSAIDS, pseudophedrine, ibuprofen)
    • "White coat syndrome" - stress caused by medical setting
  45. What level should the client's arm be at when taking BP?
    Relaxed, at heart level
  46. What is the 1st Korotkoff sound during BP?
    The 5th?
    • 1st - systole (clear tapping heard by the opening of the artery and blood flowing in)
    • 5th - diastole (silence)
  47. How would you find the proper size blood pressure cuff for a client?
    • Bladder length = 80% of the arm circumference
    • Bladder width = 40% of the arm circumference

    *The bladder is only the inflatable portion of the cuff, not the entire length.
  48. How high do you inflate the blood pressure cuff before realsing the air?
    20-30 mm beyond the point of brachial pulse obliteration
  49. How long do you wait between taking BP measurements in teh same arm?
    15 seconds
  50. Your client has a higher BP in the right arm than the left, which measurement do you use?
    Always use the higher of the two measurements
  51. If you did not pump the cuff up high enough, how would this affect your reading?
    this would give you a falsely low BP
  52. If the BP cuff is too small, how would this affect your reading?
    Too large?
    • Too small - false high
    • Too large - false low
  53. Errors when taking BP
    • Cuff size
    • Arm position
    • Cuff too loose
    • Deflated too quickly
    • Not inflated enough
    • 15 seconds not waited between measurements
  54. Paradoxical pulse
    • A difference in the systolic BP while during inspiration v. expiration
    • A normal difference is 5mm
    • A paradoxical pulse is >10 mm
  55. You find your client has a 15 mm diiference in Systolic BP during inspiration v. expiration. What could this signify?
    • This is a paradoxical pulse
    • Often indicative of a serious condition (cardiac tamponade, constrictive pericarditis, emphysema)
  56. Orthostatic hypotension
    • A significant drop in BP when position is changed
    • Drop in SBP > 20 mm or increase in pulse rate > 20 bpm when position is changed
  57. What could be a cause of orthostatic hypotension?
    orthostatic hypotension is caused by: peripheral vasodilation without a compensatory increase in CO2

    • May be found with: Hypovolemia (dehydration)
    • Bedrest
    • Medications (vasodilators)
  58. Your client reports dizziness when standing. What would you assess for?
    Orthostatic hypotension
Card Set
N202 Exam 1
N202 Exam 1