AHA Finals Study Notes
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Questions and Answers

What is the correct term to document difficulty in initiating urination?

  • Dysphagia
  • Orthopnea
  • Paraxial dyspnea
  • Hesitancy (correct)

Which terminology should be used to indicate a patient's difficulty with swallowing?

  • Apraxia
  • Orthoepic
  • Dysphagia (correct)
  • Hemiplegia

How should you document an elderly patient who repeats the same story due to forgetfulness?

  • MMSE (correct)
  • Anxiety disorder
  • Cognitive decline
  • Dementia

What does a weak and thready pulse indicate?

<p>Hard to palpate pulse that may fade (D)</p> Signup and view all the answers

What should be documented for a patient who describes difficulty breathing while lying down?

<p>Orthopnea (D)</p> Signup and view all the answers

Which of the following is a reliable method for checking skin mobility and turgor?

<p>Pinching the fold under the clavicle (D)</p> Signup and view all the answers

What should be assessed when a patient complains of bowel elimination issues for a month?

<p>Medication history and stool characteristics (D)</p> Signup and view all the answers

What is the focus of the Glasgow Coma Scale?

<p>Eye opening, motor response, and verbal response (D)</p> Signup and view all the answers

What is indicated by an absence of peristalsis during an early bowel obstruction assessment?

<p>Hypoactive bowel sounds (B)</p> Signup and view all the answers

In which situation should a nurse report findings to a supervisor promptly?

<p>Urine output of 10 ml per hour (B)</p> Signup and view all the answers

Which of the following indicates a normal vesicular breath sound during auscultation?

<p>Low-pitched soft sounds with longer inspiration (B)</p> Signup and view all the answers

How should the nurse assess the triceps reflex in a patient?

<p>Attempt to extend their forearm while resisting (C)</p> Signup and view all the answers

What does a Positive Romberg test indicate when the patient stands with feet together and sways?

<p>Sensory or proprioceptive dysfunction (A)</p> Signup and view all the answers

What should a nurse do if a patient's pupils are dilated and fixed?

<p>Report it promptly (A)</p> Signup and view all the answers

What is the expected sound heard during auscultation of a patient with asthma?

<p>High-pitched musical wheezes (B)</p> Signup and view all the answers

What should the nurse document if bowel sounds are absent after waiting five minutes?

<p>Absent bowel sounds (C)</p> Signup and view all the answers

Flashcards

Muscle tone

The assessment of muscle tone involves determining the degree of muscle relaxation and resistance to passive movement.

Absent bowel sounds

Absent bowel sounds indicate a lack of intestinal activity. This can be a sign of a serious medical condition.

Vesicular breath sounds

Vesicular breath sounds are normal, soft, low-pitched sounds heard over most of the lung fields. They are characterized by inspiration being longer than expiration.

Glasgow Coma Scale (GCS)

The Glasgow Coma Scale (GCS) is a neurological assessment tool used to assess the level of consciousness in patients with a head injury or other brain injury.

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Positive Romberg test

A positive Romberg test indicates a loss of balance when standing with eyes closed. This can be a sign of a neurological disorder affecting balance.

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Checking the popliteal pulse after a lower limb surgery

Checking for the popliteal pulse is crucial after lower limb surgery, as it helps assess blood flow to the leg.

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Why palpation is done last during abdominal assessment

Palpation can stimulate intestinal activity and potentially mask true bowel sounds. It's preferred to palpate the abdomen last during assessment.

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Dilated and fixed pupils

Dilated and fixed pupils are a critical sign of increased intracranial pressure. This needs immediate reporting to a supervisor.

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Hesitancy (Urination)

Difficulty initiating urination. This means the person has trouble starting to urinate.

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Dysphagia

Difficulty swallowing food or liquids. It can be caused by various factors like muscle weakness, nerve problems, or structural issues in the throat.

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Orthopnea

Shortness of breath that occurs when lying flat. The person needs to sit up or stand to breathe comfortably.

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Skin Turgor

The ability of the skin to return to its normal position after being pinched. It helps assess the patient's hydration status.

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Mini-Mental State Examination (MMSE)

A tool used to assess a person's cognitive function. It evaluates orientation, memory, attention, language, and other cognitive skills.

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Glasgow Coma Scale

A scale used to assess a person's level of consciousness. It evaluates eye opening, verbal response, and motor response.

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General Survey

A comprehensive assessment that includes observation of the patient's overall appearance, gait, behavior, and mental status.

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CAGE Test

A test that screens for alcohol dependence. It asks questions about cutting down, annoyed by criticism, guilty feelings, and eye-openers.

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Study Notes

AHA Finals Study Notes

  • Neuromuscular Status Check: Assess limb for skin tone (pale, cool), and muscle tone (spasticity, flaccidity).

  • Bowel Obstruction: Absent peristalsis is a sign of early bowel obstruction (hypoactive). Report urine output less than 30ml per hour.

  • Pulse Assessment: If unable to palpate left dorsalis pedis pulse, assess for popliteal pulse.

  • Respiratory Assessment: Listen for breath sounds (low pitched sounds, longer inspiration than expiration) and note any abnormal lung sounds or location discrepancy.

  • Abdominal Assessment: Palpate the abdomen at the end to avoid inhibiting peristalsis.

  • Glasgow Coma Scale: A 6-point scale used to assess a patient's level of consciousness.

  • Consensual Light Reflex: Shine light into one eye and observe the eye movement (pupillary constriction) in the opposite eye.

  • Checking Pupil Response: Note any dilated or fixed pupils and report immediately.

  • Upper Motor Neuron Function Test: Patient should be able to demonstrate the ability to pick out particular areas of pain.

  • Pain Assessment: Assess the patient's response to pain, differentiating between sharp and dull sensations.

  • Muscle Strength Assessment: Assess the patient's ability to perform tasks such as extending their forearms or flexing their arms.

  • Asthma Patient Wheezes: Wheezes indicate airway narrowing and may be high-pitched, musical sounds upon auscultation.

  • Kyphosis: Exaggerated curvature of the thoracic spine, often present in older individuals.

  • Bowel Sounds: Absence of sounds after 5 minutes.

  • Post-Knee Surgery: Check for pedal pulses in patients who undergo knee surgeries.

  • Other Assessments: Various assessment procedures for additional observations, such as determining skin color, and mental health (cognition, behaviour, and mental appearance).

  • Assessment of Urination: Determine if the patient has difficulty initiating urination.

  • Respiratory Assessment During Obstructions: Note for decreased or absent breath sounds where there is bronchial obstruction.

  • Thoracic Alignment: Assess for any unusual configurations of the chest.

  • Pulse: Observe pulses in various locations (eg. dorsalis pedis, popliteal, pedal) and note any characteristics (like strength or rhythm).

  • Muscle strength: Check for five-point muscle strength, assessing limb movements.

  • Skin Temperature: Observe skin temperature, comparing bilaterally.

  • Skin Turgor: Evaluate skin elasticity and hydration by gently pinching skin.

  • Neurological Assessment: Assess motor function (full range of motion).

  • **Verbal Response:**Assess for verbal interactions and responsiveness.

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AHA Finals PDF

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.

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