Podcast
Questions and Answers
During the introduction phase of a head-to-toe assessment, which action demonstrates verifying the patient’s identity?
During the introduction phase of a head-to-toe assessment, which action demonstrates verifying the patient’s identity?
- Washing your hands thoroughly.
- Explaining the assessment in medical terminology.
- Asking the patient their name and date of birth. (correct)
- Ensuring the room is well-lit.
A patient is oriented to person, place, and time. How would this be documented?
A patient is oriented to person, place, and time. How would this be documented?
- A&O × 4 (correct)
- O × 2
- O × 1
- A&O × 3
What is the expected range for a normal adult pulse rate in beats per minute (bpm)?
What is the expected range for a normal adult pulse rate in beats per minute (bpm)?
- 101-120 bpm
- 60-100 bpm (correct)
- 121-140 bpm
- 40-50 bpm
What is the expected range for normal oxygen saturation?
What is the expected range for normal oxygen saturation?
During the head and face assessment, what technique is used when assessing the head, scalp, and hair?
During the head and face assessment, what technique is used when assessing the head, scalp, and hair?
When assessing cranial nerve 7, which facial movement would the nurse ask the patient to perform?
When assessing cranial nerve 7, which facial movement would the nurse ask the patient to perform?
What does PERRLA assess?
What does PERRLA assess?
When examining the neck, what is being assessed when checking skin turgor under the clavicle?
When examining the neck, what is being assessed when checking skin turgor under the clavicle?
What is a key step when assessing the posterior chest?
What is a key step when assessing the posterior chest?
During the anterior chest assessment, which of the following is evaluated by palpation?
During the anterior chest assessment, which of the following is evaluated by palpation?
During auscultation of the heart, which finding would require further investigation?
During auscultation of the heart, which finding would require further investigation?
Which of the following vital signs is within normal limits?
Which of the following vital signs is within normal limits?
To accurately auscultate heart sounds, which equipment and technique should be used?
To accurately auscultate heart sounds, which equipment and technique should be used?
During an anterior chest assessment, noting the use of accessory muscles can indicate what condition?
During an anterior chest assessment, noting the use of accessory muscles can indicate what condition?
When inspecting the eyes, what does the term 'conjunctiva' refer to?
When inspecting the eyes, what does the term 'conjunctiva' refer to?
Flashcards
Inspection (Physical Exam)
Inspection (Physical Exam)
The process of examining the patient's body using the senses of sight, smell, and hearing to detect any abnormalities or significant findings.
Palpation (Physical Exam)
Palpation (Physical Exam)
Involves using the hands to feel for any abnormalities, such as lumps, masses, or areas of tenderness.
Percussion (Physical Exam)
Percussion (Physical Exam)
Involves tapping the body with the fingertips to assess the underlying tissues and organs.
Auscultation (Physical Exam)
Auscultation (Physical Exam)
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A&O x4
A&O x4
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PERRLA
PERRLA
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Normal Pulse
Normal Pulse
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Normal Blood Pressure
Normal Blood Pressure
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Normal O2 Saturation
Normal O2 Saturation
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Normal Temperature
Normal Temperature
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Normal Respirations
Normal Respirations
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Facial Nerve
Facial Nerve
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Abnormal Heart Sounds
Abnormal Heart Sounds
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Study Notes
- Head-to-toe assessment guide
Introduction
- Knock before entering
- Introduce yourself
- Wash your hands
- Provide privacy
- Verify patient ID and date of birth
- Explain what you are doing in non-medical terms
Orientation
- Ask the patient:
- What is your name?
- Do you know where you are?
- Do you know what month it is?
- Who is the current U.S. president?
- What are you doing here?
- A&O X4 = Oriented to Person, Place, Time, and Situation
"Normal" Vital Signs
- Pulse should be 60-100 bpm
- Blood pressure should be 120/80 mmHg
- O2 saturation should be 95-100%
- Temperature should be 97.8-99.1°F
- Respirations should be 12-20 breaths per minute
Head & Face
- Inspect and palpate the head, scalp, and hair
Face
- Inspect the face
- Check for symmetry
- To assess Cranial Nerve 7, check the following:
- Can they raise their eyebrows?
- Can they smile?
- Can they frown?
- Can they show teeth?
- Can they puff out their cheeks?
- Can they tightly close their eyes?
Eyes
- Inspect external eye structures
- Inspect the color of the conjunctiva and sclera
- Assess PERRLA
- Pupils Equal, Round, Reactive to Light, & Accommodation
Neck, Chest (Lungs) & Heart
- Inspect and palpate the neck
- Palpate the carotid pulse
- Check skin turgor under the clavicle
Posterior Chest
- Inspect the posterior chest
- Auscultate lung sounds in the posterior and lateral chest
- Note any crackles or diminished breath sounds
Anterior Chest
- Inspect:
- Use of accessory muscles
- AP to transverse diameter
- Sternum configuration
- Palpate: symmetric expansion
- Auscultate lung sounds in the anterior and lateral locations
- Note any crackles or diminished breath sounds
Heart
- Auscultate heart sounds (A, P, E, T, M) with a diaphragm and bell
- Note any murmurs, whooshing, bruits, or muffled heart sounds
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