HHA EXAM 1: GENERAL SURVEY AND VITAL SIGNS
EXAM WITH ALL CORRECT & 100% VERIFIED ANSWERS
when does the general survey begin Correct answer-during the interview phase of health
assessment; the second you see the pt
what are some things being observed in a general survey Correct answer-physical development
and body build, gender and sexual development, skin condition and color, dress and hygiene, posture
and gait, level of consciousness, behaviors, facial expressions, and speech
what are the important indications of the patient's physiological status, and response to the
environment Correct answer-vital signs
what are the 5 indicators of an urgent assessment Correct answer-1. extreme anxiety
2. acute distress
3. pallor (pale and on darker complexions look at their lips)
4. cyanosis (blue meaning pt is not getting enough O2)
5. mental status change (loss of consciousness)
when pt is experiencing a loss of consciousness (LOC) what is typically the first thing lost (sense of
time, location or who they are) then when comes after that Correct answer-Time is typically loss
first so important to ask them if they know what day it or
- next is place so ask them if they know where they are
- last thing loss is who they are so asking their name and DOB
what are some indications that the rapid response team would need to be alerted because our pt is
most likely about to code
- think about mental status, respirations, pulses, BP, temperature Correct answer-1. acute change
in mental status
2. stridor (wheezing noise indicative of tracheal obstruction)
3. respirations (less than 10/slow or more than 32/fast breaths a min)
4. increasing effort to breathe
5. oxygen saturation less than 92%
6. pulses (less than 55/slow or more than 120/fast beats/min)
7. Systolic Bp <100/low or >120/high mmHG
8. Temperature <35C/hypothermic or >39.5C/hyperthermic
9. new onset of chest pain
10. agitation and restlessness
before observing vital signs, what should the nurse do Correct answer-tell the pt what they are
about to do before you start touching them
when every pt is admitted, what two things are done and why Correct answer-every pt admitted
gets their height and weight (in kg) collected in order to administer meds because some meds are
dependent on weight
a scale and height bar are used for adults so what is used for infants Correct answer-a tape
measure; especially for head circumference which is done until they are 2 years of age
before measuring vital signs, what 4 things should be done Correct answer-1. have the pt rest at
least 5 min
, 2. assure that the pr has not eaten, drank or smoked at least 30 min before measurement
3. remove clothing constrictive to the upper arm
4. pt may be sitting or standing
what are the 4 vital signs that are performed Correct answer-1. temperature
2. pulse
3. respirations
4. blood pressure
what is the normal body temp for an adult Correct answer-36.5C to 37C (97.7F to 98.6F)
appropriate route selection for taking a temperature should be selected how Correct answer-by
critical thinking
what are the 5 routes of administering temperature Correct answer-rectal, temporal, axillary, oral
and tympanic
rectal and temporal artery sites measure higher or lower than oral measurements Correct answer-
they measure more then oral measurements
axillary measurements measure higher or lower than oral temperature measurement Correct
answer-axillary measures lower than oral measurements
therefore, which location is the most accurate Correct answer-oral
where should the probe be inserted when administering an oral temperature Correct answer-in
the left or right sublingual pocket under the tongue and their mouth needs to completely closed
which location is done mostly on kids depending on if they can't do an oral temp Correct answer-
Axillary
where should the probe be inserted when administering an axillary temp Correct answer-the
probe should be inserted under the armpit and the arm needs to be done
which location is typically done on older adult pts because many may not be speaking or cannot
open their mouth Correct answer-Rectal
infants can get a rectal temp done but why is is not the best location Correct answer-probe should
be inserted no more than 1/2inch but not recommended b/c probe can get sucked into the rectal
hole
why is a tympanic location not as accurate Correct answer-because the probe cannot touch the
inside of the ears; has to go directly in which can be very difficult
why is the temporal location accurate Correct answer-the head has to be dry in order to have an
accurate reading but the temporal location is accurate because the temporal lobe is very close to the
hypothalamus which is the temp regulating center
what are some factors that can affect body temp Correct answer-1. diurnal cycle (lowest in the
morning and highest in the evening)
2. stress
EXAM WITH ALL CORRECT & 100% VERIFIED ANSWERS
when does the general survey begin Correct answer-during the interview phase of health
assessment; the second you see the pt
what are some things being observed in a general survey Correct answer-physical development
and body build, gender and sexual development, skin condition and color, dress and hygiene, posture
and gait, level of consciousness, behaviors, facial expressions, and speech
what are the important indications of the patient's physiological status, and response to the
environment Correct answer-vital signs
what are the 5 indicators of an urgent assessment Correct answer-1. extreme anxiety
2. acute distress
3. pallor (pale and on darker complexions look at their lips)
4. cyanosis (blue meaning pt is not getting enough O2)
5. mental status change (loss of consciousness)
when pt is experiencing a loss of consciousness (LOC) what is typically the first thing lost (sense of
time, location or who they are) then when comes after that Correct answer-Time is typically loss
first so important to ask them if they know what day it or
- next is place so ask them if they know where they are
- last thing loss is who they are so asking their name and DOB
what are some indications that the rapid response team would need to be alerted because our pt is
most likely about to code
- think about mental status, respirations, pulses, BP, temperature Correct answer-1. acute change
in mental status
2. stridor (wheezing noise indicative of tracheal obstruction)
3. respirations (less than 10/slow or more than 32/fast breaths a min)
4. increasing effort to breathe
5. oxygen saturation less than 92%
6. pulses (less than 55/slow or more than 120/fast beats/min)
7. Systolic Bp <100/low or >120/high mmHG
8. Temperature <35C/hypothermic or >39.5C/hyperthermic
9. new onset of chest pain
10. agitation and restlessness
before observing vital signs, what should the nurse do Correct answer-tell the pt what they are
about to do before you start touching them
when every pt is admitted, what two things are done and why Correct answer-every pt admitted
gets their height and weight (in kg) collected in order to administer meds because some meds are
dependent on weight
a scale and height bar are used for adults so what is used for infants Correct answer-a tape
measure; especially for head circumference which is done until they are 2 years of age
before measuring vital signs, what 4 things should be done Correct answer-1. have the pt rest at
least 5 min
, 2. assure that the pr has not eaten, drank or smoked at least 30 min before measurement
3. remove clothing constrictive to the upper arm
4. pt may be sitting or standing
what are the 4 vital signs that are performed Correct answer-1. temperature
2. pulse
3. respirations
4. blood pressure
what is the normal body temp for an adult Correct answer-36.5C to 37C (97.7F to 98.6F)
appropriate route selection for taking a temperature should be selected how Correct answer-by
critical thinking
what are the 5 routes of administering temperature Correct answer-rectal, temporal, axillary, oral
and tympanic
rectal and temporal artery sites measure higher or lower than oral measurements Correct answer-
they measure more then oral measurements
axillary measurements measure higher or lower than oral temperature measurement Correct
answer-axillary measures lower than oral measurements
therefore, which location is the most accurate Correct answer-oral
where should the probe be inserted when administering an oral temperature Correct answer-in
the left or right sublingual pocket under the tongue and their mouth needs to completely closed
which location is done mostly on kids depending on if they can't do an oral temp Correct answer-
Axillary
where should the probe be inserted when administering an axillary temp Correct answer-the
probe should be inserted under the armpit and the arm needs to be done
which location is typically done on older adult pts because many may not be speaking or cannot
open their mouth Correct answer-Rectal
infants can get a rectal temp done but why is is not the best location Correct answer-probe should
be inserted no more than 1/2inch but not recommended b/c probe can get sucked into the rectal
hole
why is a tympanic location not as accurate Correct answer-because the probe cannot touch the
inside of the ears; has to go directly in which can be very difficult
why is the temporal location accurate Correct answer-the head has to be dry in order to have an
accurate reading but the temporal location is accurate because the temporal lobe is very close to the
hypothalamus which is the temp regulating center
what are some factors that can affect body temp Correct answer-1. diurnal cycle (lowest in the
morning and highest in the evening)
2. stress
