NR 304 FINAL EXAM || 100% Exact Answers.
Components of General Survey correct answers o Physical appearance- age, sex, LOC, skin
color, facial features, overall appearance,
o Body structure- stature, nutrition, symmetry, posture, position, body build, contour,
physical deformities.
o Mobility- gait, ROM, involuntary movement.
o Behavior- facial expression, mood/affect, speech, dress, personal hygiene.
o Measurement- weight, height, BMI, waist circumference
Physical appearance correct answers Age: person appears their stated age
Sex: development is appropriate for sex and age; if transgender note stage of transformation
Level of consciousness: alert and oriented to person, place, time, and situation
Skin color: color tone even, pigmentation varies, skin intact, note tattoos and piercings
Facial features: note symmetry
Overall appearance: acute distress?
Body structure correct answers Stature: height in normal range for age/genetics?
Nutrition: weight within normal range for height/build?
Symmetry: body parts equal bilaterally?
Posture: stand erect comfortably? "plumb line" through anterior ear, shoulder, hip, patella, ankle
Exceptions are toddler lordosis and aging person with kyphosis
Position: sits comfortably with arms relaxed at sides and head towards examiner
Body build, contour:
Arm span = height
,Crown to pubis ≈ pubis to sole
Obvious physical deformities?
Mobility assessment correct answers Gait: feet shoulder width apart, foot placement accurate,
walk smooth and even, maintain balance without assistance, symmetric arm swing present
Range of motion: full mobility for each joint; movement is deliberate, accurate, smooth,
coordinated;
no involuntary movement
Behavior correct answers Facial expression: maintains eye contact (if culturally appropriate),
expressions appropriate to situation
Mood and affect: person comfortable and cooperative, interacts pleasantly
Speech: articulation clear and understandable
Speech pattern: fluent with even pace, conveys ideas clearly, word choice appropriate for
culture/education, communicates easily by themselves or
with interpreter
Dress: clothing appropriate to climate and culture, clean and fits body
Personal hygiene: clean and groomed appropriately for age, occupation, socioeconomic group
o How does the patient interact with others?
Personal Hygiene
Grading Pulse Force correct answers 3+ increased, full, bounding
2+ normal
1+ weak
0 absent
, Identify Hypotension Occurrences and Rationales correct answers o Acute myocardial
infarction : decreased cardiac output
o Shock : decreased cardiac output
o Hemorrhage : decrease in total blood volume
o Vasodilation : decrease in peripheral vascular resistance
o Addison disease (hypofunction of adrenal glands) : decrease in circulating aldosterone
hypotension symptoms correct answers increased pulse
dizziness
diaphoresis
confusion
blurred vision,
cool/clammy skin.
smoking and blood pressure correct answers Nicotine causes blood vessels to constrict or narrow,
which limits the amount of blood that flows to the organs. Over time, the constant constriction
results in blood vessels that are stiff and less elastic. Constricted blood vessels decrease the
amount of oxygen and nutrients the cells receive. To meet the need for more oxygen, heart rate
may increase.
Acute pain responses correct answers CARDIAC: Tachycardia Elevated blood pressure
Increased myocardial oxygen demand Increased cardiac output.
PULMONARY: Hypoventilation Hypoxia Decreased cough Atelectasis
GASTROINTESTINAL: Nausea Vomiting Ileus
RENAL: Oliguria Urinary retention
MUSCULOSKELETAL: Spasm, Joint stiffness
ENDOCRINE: Increased adrenergic activity
CENTRAL NERVOUS SYSTEM: Fear Anxiety Fatigue
IMMUNE: Impaired cellular immunity, Impaired wound healing
Components of General Survey correct answers o Physical appearance- age, sex, LOC, skin
color, facial features, overall appearance,
o Body structure- stature, nutrition, symmetry, posture, position, body build, contour,
physical deformities.
o Mobility- gait, ROM, involuntary movement.
o Behavior- facial expression, mood/affect, speech, dress, personal hygiene.
o Measurement- weight, height, BMI, waist circumference
Physical appearance correct answers Age: person appears their stated age
Sex: development is appropriate for sex and age; if transgender note stage of transformation
Level of consciousness: alert and oriented to person, place, time, and situation
Skin color: color tone even, pigmentation varies, skin intact, note tattoos and piercings
Facial features: note symmetry
Overall appearance: acute distress?
Body structure correct answers Stature: height in normal range for age/genetics?
Nutrition: weight within normal range for height/build?
Symmetry: body parts equal bilaterally?
Posture: stand erect comfortably? "plumb line" through anterior ear, shoulder, hip, patella, ankle
Exceptions are toddler lordosis and aging person with kyphosis
Position: sits comfortably with arms relaxed at sides and head towards examiner
Body build, contour:
Arm span = height
,Crown to pubis ≈ pubis to sole
Obvious physical deformities?
Mobility assessment correct answers Gait: feet shoulder width apart, foot placement accurate,
walk smooth and even, maintain balance without assistance, symmetric arm swing present
Range of motion: full mobility for each joint; movement is deliberate, accurate, smooth,
coordinated;
no involuntary movement
Behavior correct answers Facial expression: maintains eye contact (if culturally appropriate),
expressions appropriate to situation
Mood and affect: person comfortable and cooperative, interacts pleasantly
Speech: articulation clear and understandable
Speech pattern: fluent with even pace, conveys ideas clearly, word choice appropriate for
culture/education, communicates easily by themselves or
with interpreter
Dress: clothing appropriate to climate and culture, clean and fits body
Personal hygiene: clean and groomed appropriately for age, occupation, socioeconomic group
o How does the patient interact with others?
Personal Hygiene
Grading Pulse Force correct answers 3+ increased, full, bounding
2+ normal
1+ weak
0 absent
, Identify Hypotension Occurrences and Rationales correct answers o Acute myocardial
infarction : decreased cardiac output
o Shock : decreased cardiac output
o Hemorrhage : decrease in total blood volume
o Vasodilation : decrease in peripheral vascular resistance
o Addison disease (hypofunction of adrenal glands) : decrease in circulating aldosterone
hypotension symptoms correct answers increased pulse
dizziness
diaphoresis
confusion
blurred vision,
cool/clammy skin.
smoking and blood pressure correct answers Nicotine causes blood vessels to constrict or narrow,
which limits the amount of blood that flows to the organs. Over time, the constant constriction
results in blood vessels that are stiff and less elastic. Constricted blood vessels decrease the
amount of oxygen and nutrients the cells receive. To meet the need for more oxygen, heart rate
may increase.
Acute pain responses correct answers CARDIAC: Tachycardia Elevated blood pressure
Increased myocardial oxygen demand Increased cardiac output.
PULMONARY: Hypoventilation Hypoxia Decreased cough Atelectasis
GASTROINTESTINAL: Nausea Vomiting Ileus
RENAL: Oliguria Urinary retention
MUSCULOSKELETAL: Spasm, Joint stiffness
ENDOCRINE: Increased adrenergic activity
CENTRAL NERVOUS SYSTEM: Fear Anxiety Fatigue
IMMUNE: Impaired cellular immunity, Impaired wound healing
