51 Questions
What is the term for pupils of different sizes?
Anisocoria
Which term refers to the drooping of the eyelids?
Ptosis
What does PERLA stand for in the context of eye assessment?
Pupils equal and reactive to light and accommodation
What is the term for the stimulation of one pupil with light, causing both pupils to constrict rapidly, simultaneously, and equally?
Consensual reflex
Which term is used when focusing on a distant object, causing both pupils to dilate to allow in more light?
Accommodation response
What does dysphasia refer to?
Difficulty coordinating and organizing words into sentences
What is included in the head-to-toe sequence for nursing assessment?
Pupils, neck vein distention, and apical-radial pulse strength
What is the purpose of assessing the chest during the head-to-toe sequence?
To assess heart sounds and breath sounds
What should be assessed when examining the arms during the head-to-toe sequence?
Strength of hand grips and IV or saline lock
Why is it important to assess the abdomen during the head-to-toe sequence?
To assess bowel sounds and bladder distention
What is a key aspect of assessing the perineum during the head-to-toe sequence?
Foley and incontinent. Bed dry.
Why should lower extremities be assessed during the head-to-toe sequence?
To assess skin integrity and edema
What is a crucial aspect of assessing the back and buttocks during the head-to-toe sequence?
Skin integrity and incontinent. Bed dry.
Why is it important to address comfort and needs during the head-to-toe sequence?
To reposition comfortably with pillow support if needed
Why are safety features like bed height and call light accessibility highlighted as important?
To prevent potential accidents or falls
What is the significance of reviewing the steps of each of the skills procedures?
To understand why each step is important and what could happen if they are not followed
What could happen if safety guidelines like bed low and wheels locked are not followed?
Potential accidents or falls may occur
Why is it important to understand why the steps of each skills procedure are important?
So that each step can be followed in the correct order to prevent adverse outcomes
Which of the following is a component of a basic neurological examination?
Assessment of level of consciousness
What is a normal respiratory rate?
Between 12 to 20 breaths per minute
Which of the following is an abnormal respiratory pattern characterized by an abnormally deep and rapid rate of breathing?
Tachypnea
What should be reassessed within at least a 4-hour window, or sooner depending on the severity of the finding?
Abnormal assessment findings
Which of the following is a cardiovascular assessment?
Assessment of neck vein distention
What should be assessed as part of gastrointestinal assessments?
Bowel sounds
Which assessment should include assessment of bladder palpation and last voided time?
Urinary assessment
What should be assessed as part of integumentary assessments?
Color and temperature of skin
What is assessed in musculoskeletal assessments?
Movement and range-of-motion of joints and extremities
What should be assessed during respiratory assessments?
Respiratory effort
What is assessed during a basic neurological examination?
Response to simple commands
Which of the following techniques involves tapping with the tips of the fingers over specific body parts to elicit sounds that can help locate and determine the size of structures beneath the surface?
Percussion
Which of the following is an example of a symptom?
Pain in the chest
What is the purpose of auscultation?
To hear heart, breath, and bowel sounds
Which assessment finding indicates acute respiratory distress?
Retractions
What type of data is not directly observable or measurable?
Symptoms
Which system is assessed in an initial head-to-toe shift assessment?
Respiratory
What is detected by olfaction?
$NH_3$ (ammonia)
Which technique involves tapping with the tips of the fingers over specific body parts to detect areas containing air or fluid?
Percussion
What type of data can be obtained from patient history?
Social history
What does auscultation help detect?
Heart sounds
What does percussion help identify?
Whether a structure is solid or hollow
What is the term for continuous, melodious, musical, or whistling breath sounds due to constriction of the airway?
Rhonchi
When should a nurse perform a physical assessment on a patient?
When things do not feel right
What is the term for a rapid rate of breathing?
Tachypnea
What type of assessment is performed when time constraints only allow the nurse to check one system or only the systems related to the patient’s disease process?
Focused assessment
What eye response does the nurse assess by briefly shining a penlight in one eye of a patient and observing both pupils’ response?
Consensual reflex
What is the term for a normal rate and pattern, with equal depth, of respirations?
Eupnea
Which breath sounds are caused by air moving over secretions or alveoli opening up, and can be fine or coarse and do not clear with coughing?
Crackles
What is the purpose of a physical assessment?
All of the above
What is used to assess pupil constriction of the eyes and to examine the oral and nasal mucous membranes?
Penlight
What is used to inspect the lining of the nose, tympanic membranes, and ear canals?
Otoscope
What eye response is assessed by holding a finger in front of the patient’s face and slowly increasing and then decreasing the distance between the finger and the patient’s face while observing for dilation and then constriction of pupils?
Accommodation response
Learn about the techniques used for physical assessment in nursing, including interview, inspection, percussion, auscultation, palpation, and olfaction. Understand the difference between signs and symptoms in healthcare.
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