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NR 304 FINAL EXAM Questions and
Correct Answers the Latest Update and
Recommended Version
Components of General Survey
→ 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
→ 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
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→ 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
→ 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
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→ 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
→ 3+ increased, full, bounding
→ 2+ normal
→ 1+ weak
→ 0 absent
Identify Hypotension Occurrences and Rationales
→ 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
→ increased pulse
→ diiness
diaphoresis
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