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Questions and Answers
What is the correct term to document difficulty in initiating urination?
What is the correct term to document difficulty in initiating urination?
Which terminology should be used to indicate a patient's difficulty with swallowing?
Which terminology should be used to indicate a patient's difficulty with swallowing?
How should you document an elderly patient who repeats the same story due to forgetfulness?
How should you document an elderly patient who repeats the same story due to forgetfulness?
What does a weak and thready pulse indicate?
What does a weak and thready pulse indicate?
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What should be documented for a patient who describes difficulty breathing while lying down?
What should be documented for a patient who describes difficulty breathing while lying down?
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Which of the following is a reliable method for checking skin mobility and turgor?
Which of the following is a reliable method for checking skin mobility and turgor?
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What should be assessed when a patient complains of bowel elimination issues for a month?
What should be assessed when a patient complains of bowel elimination issues for a month?
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What is the focus of the Glasgow Coma Scale?
What is the focus of the Glasgow Coma Scale?
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What is indicated by an absence of peristalsis during an early bowel obstruction assessment?
What is indicated by an absence of peristalsis during an early bowel obstruction assessment?
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In which situation should a nurse report findings to a supervisor promptly?
In which situation should a nurse report findings to a supervisor promptly?
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Which of the following indicates a normal vesicular breath sound during auscultation?
Which of the following indicates a normal vesicular breath sound during auscultation?
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How should the nurse assess the triceps reflex in a patient?
How should the nurse assess the triceps reflex in a patient?
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What does a Positive Romberg test indicate when the patient stands with feet together and sways?
What does a Positive Romberg test indicate when the patient stands with feet together and sways?
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What should a nurse do if a patient's pupils are dilated and fixed?
What should a nurse do if a patient's pupils are dilated and fixed?
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What is the expected sound heard during auscultation of a patient with asthma?
What is the expected sound heard during auscultation of a patient with asthma?
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What should the nurse document if bowel sounds are absent after waiting five minutes?
What should the nurse document if bowel sounds are absent after waiting five minutes?
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Study Notes
AHA Finals Study Notes
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Neuromuscular Status Check: Assess limb for skin tone (pale, cool), and muscle tone (spasticity, flaccidity).
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Bowel Obstruction: Absent peristalsis is a sign of early bowel obstruction (hypoactive). Report urine output less than 30ml per hour.
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Pulse Assessment: If unable to palpate left dorsalis pedis pulse, assess for popliteal pulse.
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Respiratory Assessment: Listen for breath sounds (low pitched sounds, longer inspiration than expiration) and note any abnormal lung sounds or location discrepancy.
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Abdominal Assessment: Palpate the abdomen at the end to avoid inhibiting peristalsis.
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Glasgow Coma Scale: A 6-point scale used to assess a patient's level of consciousness.
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Consensual Light Reflex: Shine light into one eye and observe the eye movement (pupillary constriction) in the opposite eye.
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Checking Pupil Response: Note any dilated or fixed pupils and report immediately.
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Upper Motor Neuron Function Test: Patient should be able to demonstrate the ability to pick out particular areas of pain.
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Pain Assessment: Assess the patient's response to pain, differentiating between sharp and dull sensations.
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Muscle Strength Assessment: Assess the patient's ability to perform tasks such as extending their forearms or flexing their arms.
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Asthma Patient Wheezes: Wheezes indicate airway narrowing and may be high-pitched, musical sounds upon auscultation.
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Kyphosis: Exaggerated curvature of the thoracic spine, often present in older individuals.
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Bowel Sounds: Absence of sounds after 5 minutes.
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Post-Knee Surgery: Check for pedal pulses in patients who undergo knee surgeries.
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Other Assessments: Various assessment procedures for additional observations, such as determining skin color, and mental health (cognition, behaviour, and mental appearance).
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Assessment of Urination: Determine if the patient has difficulty initiating urination.
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Respiratory Assessment During Obstructions: Note for decreased or absent breath sounds where there is bronchial obstruction.
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Thoracic Alignment: Assess for any unusual configurations of the chest.
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Pulse: Observe pulses in various locations (eg. dorsalis pedis, popliteal, pedal) and note any characteristics (like strength or rhythm).
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Muscle strength: Check for five-point muscle strength, assessing limb movements.
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Skin Temperature: Observe skin temperature, comparing bilaterally.
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Skin Turgor: Evaluate skin elasticity and hydration by gently pinching skin.
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Neurological Assessment: Assess motor function (full range of motion).
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**Verbal Response:**Assess for verbal interactions and responsiveness.
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Description
Prepare for your AHA finals with these essential study notes. This quiz covers key assessments including neuromuscular status, bowel obstruction signs, and the Glasgow Coma Scale. Test your knowledge on crucial medical evaluations and ensure you're ready for the exam.
