NEURO KNOW HOW
WHICH CRANIAL NERVES ARE ASSESSED WHEN TESTING THE "CAT WHISKER" EYE MOVEMENT PATTERN?
3, 4, 6
III, IV, VI
WHERE IS THE POINT OF MAXIMAL IMPULSE OR PMI LOCATED?
(5th ICS, MCL
The nurse notes use of accessory muscles and nasal flaring. What does this suggest?
Respiratory distress;
What quadrant do you start with during abdominal auscultation?
(Right Lower Quadrant)
What does the term “turgor” refer to in a skin assessment
(Skin elasticity/hydration status)
A PATIENT IS ALERT BUT CONFUSED ABOUT TIME AND PLACE HOW WOULD YOU DOCUMENT THE LEVEL OF CONSCIOUSNESS
What is a bruit and where might you auscultate for it?
(Turbulent blood flow; carotid artery)
You hear high-pitched musical sounds during expiration. What breath sound is this
Wheezing;
What is a normal finding for bowel sounds?
(Gurgling sounds every 5–15 seconds)
What does clubbing of the nails typically indicate?
(Chronic hypoxia, often from lung disease)
When assessing PERRLA, which cranial nerves are involved and what is the expected finding?
(CN II and III; pupils equal, round, reactive to light and accommodation)
What is the grading scale range for pulses and what is normal?
(0 to 4+, with 2+ being normal)
Explain egophony and what a positive test indicate
(Ask patient to say "ee"; if sounds like "ay" over area, indicates consolidation—e.g., pneumonia)
What is rebound tenderness and what condition might it suggest
(Pain upon release = peritoneal inflammation, e.g., appendicitis)
Explain what cyanosis, pallor, and jaundice each ARE?
CYANOSIS-BLUISH TINT
PALLOR-PALENESS
JAUNDICE-YELLOWING
Which cranial nerve is assessed by having the patient shrug their shoulders against resistance?
(CN XI – Spinal Accessory)
11
Which pulse site is best for assessing circulation to the lower leg?
The dorsalis pedis or posterior tibial artery.
What does the presence of crackles (rales) suggest?
(Fluid in alveoli,
What is the significance of a positive Murphy’s sign?
(Pain on inspiration during RUQ palpation = cholecystitis)
What might unilateral edema of a lower limb indicate and what is the immediate nursing concern?
(Possible deep vein thrombosis; assess further, notify provider)
Differentiate between assessing stereognosis and graphesthesia
(Stereognosis = object identification by touch; Graphesthesia = recognize writing on skin;
A nurse hears a murmur during systole at the second intercostal space, right sternal border. What valve is likely involved and what condition might it indicate?
(Aortic valve; possible aortic stenosis)
Differentiate between vesicular, bronchial, and bronchovesicular breath sounds based on location and character
(Vesicular: soft/low over lungs; Bronchial: loud/high over trachea; Bronchovesicular: moderate over mainstem bronchi)
During palpation, a firm, non-tender liver edge is felt 5 cm below the costal margin. What does this suggest and what further assessment is needed?
Possible hepatomegaly;
What are ABCDEs of mole assessment?
(Asymmetry, Border, Color, Diameter, Evolving)