Documentation
List subjective questions that should be asked if a patient comes in regarding ear pain?
Severity of pain, earaches, infections, discharge, hearing loss, vertigo
What is Tandem Gait?
Normal heel to toe walking
What are the two pathways of the Central Nervous Sytem?
Sensory and Motor
What is the name of the cranial nerve that is tested by having a patient raising their shoulders, and turning their face from side to side?
Spinal Accessory
What type of database is most appropriate when rapid collection of data is required and often compiled concurrently with lifesaving measures?
Emergency Database
If you see in the chart the term "Synarthroses", what does this mean?
Immoveable, in reference to a joint
The part of the diagnostic process (ADPIE) that determines outcome criteria and developing a plan.
Planning
What is the lacrimal apparatus?
The tear system
If a patient comes in and reports changes of vision, what cranial nerves would you want to assess?
Cranial nerves 2, 3, 4, 6
A patient comes into the Emergency Department with complaints of a severe headache and a blood pressure of 188/101. What is your first priority as the RN?
Report findings to the physician.
When documenting about an abnormal lesion on the skin, what do you want to chart when following the ABCDE rule?
Asymmetry, Border, Color, Diameter, Elevation and Enlargement
When completing a respiratory assessment on a client, what are you, as the nurse, physically assessing for that could indicate respiratory distress?
Retractions
Where is the Angle of Louis located?
2nd Intercostal Space
What screenings are performed for Cranial Nerve VIII? Describe each test.
Romberg, Whisper, Rinne
ou’re performing a head-to-toe assessment on a patient admitted with abdominal pain. During inspection of the abdomen, you note the abdominal contour to be round and distended with no masses or lesions present. The patient reports that their last bowel movement was one hour ago, and the stool was loose. In addition, the patient states that the abdominal pain is located below the umbilicus and is sharp in quality. After inspection of the abdomen, what is your next step as the RN?
Auscultate the abdomen
If you were see documented that a patient had uterine enlargement, what could be some reasons for this?
Pregnancy, Uterine Fibroids, Carcinoma, Endometriosis
List the developmental skin changes for the older adult.
Wrinkles, loss of subcutaneous fat, diminished elasticity, keratosis
List the components of an ECG.
P wave, PR interval, QRS complex, T wave
During the time of COVID-19, what Cranial Nerve was commonly effected?
Cranial Nerve 1
A client diagnosed with asthma has been admitted to the step-down unit. What lung sounds would you expect to find with this type of patient?
Wheezes
What test would be expected to be documented to determine occult blood?
Hematest
What is an example of Discrete skin lesions?
Demonstrate Abduction and Adduction.
Abduction - Away from body
Adduction - Toward the body
What are you assessing for when assessing cranial nerve XII?
Speech and Articulation, movement of the tongue
Number the priority of the following conditions using the numbers # 1 through # 6 with # 1 as the greatest priority and # 6 as the least priority.
4. An obstructed airway
2. First degree heart block
1. Atrial fibrillation
3. Shortness of breath upon exertion
5. Fluid needs
6. Respect and esteem by others