Podcast
Questions and Answers
What are the indicators of a cooperative and friendly neuro assessment?
What are the indicators of a cooperative and friendly neuro assessment?
Maintains eye contact, speech clear and appropriate, oriented X3.
What does PERRLA stand for in a neuro assessment?
What does PERRLA stand for in a neuro assessment?
Pupils Equal, Round, Reactive to Light and Accommodation at 3mm.
What should be assessed in the neuro (M/S) evaluation?
What should be assessed in the neuro (M/S) evaluation?
Full ROM (range of motion) in neck, arms, and legs without pain.
What is considered a normal respiratory rate?
What is considered a normal respiratory rate?
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What should the apical pulse be in a cardiovascular assessment?
What should the apical pulse be in a cardiovascular assessment?
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What findings could indicate abnormalities in the GI/GU assessment?
What findings could indicate abnormalities in the GI/GU assessment?
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What should the skin assessment reveal?
What should the skin assessment reveal?
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What are the comments noted during the assessment?
What are the comments noted during the assessment?
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Study Notes
Neuro (Psycho/Social)
- Patient exhibits cooperative and friendly demeanor.
- Maintains eye contact; speech is clear, appropriate, and at a normal rate.
- Oriented to person, place, and time.
- Self-reported feeling "in good health."
Neuro (Head & Neck)
- Facial symmetry observed.
- Pupils equal, round, reactive to light and accommodation (PERRLA) at 3mm.
- Occulomotor movements are even and coordinated.
- Equal hand grip strength noted; Hypoglossal (CN12) and Spinal Accessory (CN11) nerves function properly.
Neuro (M/S)
- Neck demonstrates full range of motion (ROM) without pain.
- Arms and legs show full ROM without pain.
- Dorsiflexion and plantar flexion are equal bilaterally.
- Lower limb abduction and adduction are equal bilaterally.
- Full muscle strength is present across all limbs.
Respiratory (RESP)
- Respiratory rate recorded at 16 breaths per minute, with normal depth.
- No shortness of breath while breathing room air.
- Patient can cough without experiencing pain.
- Tactile fremitus is present bilaterally; chest excursion is symmetric.
- Trachea is midline with no adventitious breath sounds noted.
- No wheezes, crackles, or rhonchi detected in lung regions, both anterior and posterior.
Cardiovascular (CV)
- Apical impulse located at the 5th intercostal space (ICS) in the left midclavicular line (MCL).
- Heart rate recorded at 72 beats per minute, with no reduction in sounds during S1 to S2.
- No murmurs, gallops, or clicks detected in any heart valves (aortic, pulmonic, tricuspid, and mitral).
- Carotid pulses are strong bilaterally with no bruits.
- All peripheral pulses are present and rated 2+: radial, brachial, dorsal pedal, and posterior tibial.
- No edema or varicosities present, with no calf tenderness noted.
- Jugular veins appear flat with no jugular venous distention (JVD) in supine position.
- Skin is warm, dry, well-perfused, with no signs of cyanosis.
Gastrointestinal/Genitourinary (GI/GU)
- Abdomen is round and symmetrical with midline umbilicus.
- Skin intact with no signs of striae, lesions, or scars.
- No masses palpated and no tenderness reported by the patient.
- Bowel sounds present and active in all four quadrants.
- Last bowel movement was on 12/11/15: long, brown, and soft with no straining.
- Last micturation also on 12/11/15: clear, not cloudy, yellow, with no abnormal odor.
Skin
- Skin is warm to touch, dry, and intact with no visible lesions, scars, abrasions, or bruises.
- Skin turgor is present with no tenting observed.
- Even distribution of hair noted; scalp appears normal with no infestations or dandruff.
- Mucous membranes in nares and mouth are pink and moist without lesions or redness.
- No redness above bony structures in head, thorax, or legs indicating potential pressure ulcers.
Comments
- No discomfort reported; patient remains comfortable throughout the assessment.
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Description
This quiz focuses on the comprehensive head to toe assessment documentation, including neurological evaluations for both psycho/social and head & neck components. Each flashcard covers key definitions and observations essential for accurate patient assessments. Perfect for nursing students and healthcare professionals looking to enhance their documentation skills.
