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HA - MODULE 4
| Question | Answer |
|---|---|
| It is the systematic observation of a client’s overall appearance, level of comfort, mental status, and measurement of vital signs, height, and weight. | General Survey |
| What are the key components assessed during a General Survey? | General appearance, level of comfort, mental status, vital signs, height, and weight. |
| What materials are needed to perform a General Survey? | Privacy curtains or locked doors, quiet and well-lit environment, stable chair or hospital bed, penlight, clean gloves, ruler or tape measure, trash bin for infectious waste, and paper and pen for documentation. |
| What is the first nursing action before assessing appearance and mental status? | Introduce oneself, verify the client’s identity, explain the procedure, its purpose, and how the client can participate. |
| Why is client privacy important during assessment? | Privacy ensures comfort, cooperation, dignity, and accurate assessment findings. |
| What is a normal finding related to posture and facial expression? | No signs of distress; relaxed posture and neutral facial expression. |
| What are abnormal signs of distress in posture or facial expression? | Bending over due to pain, wincing, frowning, or labored breathing. |
| What is considered normal body build, height, and weight? | Proportionate to the client’s age, lifestyle, and health status. |
| What deviations indicate abnormal body build? | Excessive thinness or obesity. |
| What is a normal posture and gait? | Relaxed, erect posture with coordinated movement. |
| What are abnormal posture and gait findings? | Slouched or bent posture, uncoordinated movement, tremors, dirty or unkempt appearance. |
| What indicates normal hygiene and grooming? | Clean and neat appearance |
| What considered normal body and breath odor in relation to activity level. | No body/breath odor or minor body odor relative to work or exercise |
| What abnormal odors may indicate health problems? | Foul body odor, ammonia odor, acetone breath odor, or foul breath. |
| What deviation indicates abnormal signs of health or illness | Pallor(loss of color in the skin), weakness, obvious illness |
| What is a normal attitude during assessment? | Cooperative behavior. |
| What are abnormal attitudes observed during assessment? | Negative, hostile, or withdrawn behavior. |
| What is normal speech during mental status assessment? | Understandable speech with moderate pace and logical thought association. |
| What speech characteristics indicate abnormal findings? | Rapid or slow pace, overly loud or soft speech, lack of thought association. |
| What defines logical thought processes? | Organized, relevant, reality-based thinking that makes sense. |
| What abnormal thought processes may be observed? | Illogical sequence, flight of ideas, or confusion. |
| What should nurses do after completing the General Survey? | Document findings and perform focused assessments on systems with abnormal findings. |
| What is the integumentary system and its main organ? | The integumentary system consists of the skin, hair, and nails; the skin is the largest organ of the body. |
| What are the main functions of the skin? | Protection, temperature regulation, fluid and electrolyte balance, sensation, immunity, absorption, excretion, and vitamin D synthesis. |
| How is the skin assessed? | Through inspection and palpation of the entire skin surface. |
| What are normal variations in skin color? | Light to deep brown or ruddy pink to light pink. |
| It is Decreased skin color due to lack of oxyhemoglobin, commonly caused by anemia or reduced arterial perfusion. | Pallor |
| It is a bluish discoloration of the skin due to inadequate oxygenation; may be peripheral or central. | Cyanosis |
| A yellow discoloration of the skin, sclera, mucous membranes, and excretions. | Jaundice |
| A Redness of the skin caused by capillary congestion. | Erythema |
| It is a small hemorrhagic spots caused by capillary bleeding | Petechiae |
| A collection of blood in the subcutaneous tissues causing purplish discoloration | Ecchymosis |
| What is normal skin uniformity? | Generally uniform color except sun-exposed areas. |
| What indicates abnormal skin uniformity? | Hyperpigmentation or hypopigmentation. |
| What is edema? | Abnormal accumulation of fluid in tissues. |
| Where is edema best assessed? | Over the tibia, medial malleolus, and dorsum of the feet. |
| Over the tibia, medial malleolus, and dorsum of the feet. | Skin springs back immediately after being pinched. |
| What does decreased skin turgor indicate? | Dehydration or poor hydration status. |
| What is normal hair distribution? | Evenly distributed, resilient hair. |
| What is alopecia? | Partial or complete loss of hair. |
| What hair changes are seen in hypothyroidism? | Thin and brittle hair. |
| What should nurses do after completing the General Survey? | Document findings and perform focused assessments on systems with abnormal findings. |
| What is the integumentary system and its main organ? | The integumentary system consists of the skin, hair, and nails; the skin is the largest organ of the body. |
| What are the main functions of the skin? | Protection, temperature regulation, fluid and electrolyte balance, sensation, immunity, absorption, excretion, and vitamin D synthesis. |
| How is the skin assessed? | Through inspection and palpation of the entire skin surface. |
| What are normal variations in skin color? | Light to deep brown or ruddy pink to light pink. |
| It is Decreased skin color due to lack of oxyhemoglobin, commonly caused by anemia or reduced arterial perfusion. | Pallor |
| It is a bluish discoloration of the skin due to inadequate oxygenation; may be peripheral or central. | Cyanosis |
| A yellow discoloration of the skin, sclera, mucous membranes, and excretions. | Jaundice |
| A Redness of the skin caused by capillary congestion. | Erythema |
| It is a small hemorrhagic spots caused by capillary bleeding | Petechiae |
| A collection of blood in the subcutaneous tissues causing purplish discoloration | Ecchymosis |
| What is normal skin uniformity? | Generally uniform color except sun-exposed areas. |
| What indicates abnormal skin uniformity? | Hyperpigmentation or hypopigmentation. |
| What is edema? | Abnormal accumulation of fluid in tissues. |
| Where is edema best assessed? | Over the tibia, medial malleolus, and dorsum of the feet. |
| Over the tibia, medial malleolus, and dorsum of the feet. | Skin springs back immediately after being pinched. |
| What does decreased skin turgor indicate? | Dehydration or poor hydration status. |
| What is normal hair distribution? | Evenly distributed, resilient hair. |
| Partial or complete loss of hair. | Alopecia |
| What hair changes are seen in hypothyroidism? | Thin and brittle hair. |
| Excessive hair growth in women in male-pattern areas. | Hirsutism |
| It is a crescent-shaped area located at the base of the nail | Lunula |
| What is the normal nail plate angle? | Approximately 160 degrees. |
| It is a flattened angle of nail with 180 degrees | Early clubbing |
| Greater than 180 degree of nail | Late clubbing |
| What is clubbing and what does it indicate? | Increased nail curvature due to chronic oxygen deficiency. |
| What is normal capillary refill time? | Less than 2 seconds. |
| It is the Infection of the tissues surrounding the nail. | Paronychia |
| What does delayed capillary refill suggest? | Poor peripheral circulation. |
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