Skin/Hair/Nails
Head/Face/
Mouth/Neck
Mouth/Neck
Ears
Eyes
Health History
Wounds
100
These compose of the Integumentary system and contribute to an individual's own unique appearance.
(hint 5 items)
What are skin, hair, nails, glands, and mucous membranes.
100
This simple bedside diagnostic test can be performed without a physician order and completed by observation with foods or fluids.
What is a swallowing evaluation?
100
This may be inherited, caused by maternal rubella or complications at birth, certain infectious diseases such as meningitis, chronic ear infections, use of ototoxic drugs, exposure to excessive noise, and aging..
What is hearing loss?
100
This is a buildup of intraocular pressure that damages the eyes optic nerve causing loss of peripheral vision.
What is Glaucoma?
100
Changes in this can be related to nutrition, stress, systemic disease, vitamin or iron deficiency, infection, and biting or picking..
What are changes in the nails?
100
It is imperative to assess this........ especially for someone at risk for impaired skin integrity.
What is nutritional status?
200
This lesion: is raised, round, or oval and filled with serous blood or clear fluid. (example: herpes simplex)
What is a vesicle?
200
These cancer risk factors refer to: Genetics, occurs three times more often in women, diets low in iodine, exposure to radiation.
What is thyroid cancer?
200
This organ of hearing serves as the microphone in the ear, converting sound impulses and vibrations from the outer ear into electric impulses that are sent to the brain via the acoustic nerve (cranial nerve VIII)..
What is the cochlea?
200
This is a device to measure intraocular pressure (IOP); the device measures the outflow of the aqueous humor from the eye (screening test for glaucoma).
What is tonometry?
200
Changes in this can be related to diet, stress, genetics, infections, and endocrine disorders..
What are changes in hair?
200
Name this tissue in the wound base.
What is Eschar?
300
The best location to assess this is the clavicle area, but may also be done on the lower arm or abdomen. Pinch the skin between two fingers and let go.
What is assessing skin turgor?
(In a well-hydrated person, the skin returns to flat position immediately. In a dehydrated person or someone w/ extreme weight loss the skin remains tented and slowly returns to flat position. Skin turgor greater than 3 sec may be related to fluid loss.)
300
This is a common side effect from the following drugs:
Anticholinergics, anticonvulsants, antidepressants, antihistamines, antihypertensives, antineoplastics
What is xerostomia? (dry mouth)
300
Otoscope and tuning fork
What are equipment needed to assess the ears?
300
This refers to the inability to see from side to side or up and down without moving the eyes or turning the head.
What is loss of visual field?
300
Tension, cluster, sinus, and migraine are all included in assessing this body part..
What is the head?
300
Stage this pressure injury..
What is stage 2?
400
A= Asymmetry
B= Border
C= Color
D= Diameter
E= Evolving
This ABCDE mnemonic is used to assess:
What are moles?
400
This is considered a medical emergency if is last longer than 30 minutes, interferes with breathing, or is following an injury..
What is epistaxis? (nosebleed)
400
These are what kind of signs of hearing loss; leaning forward, tilting the head and ear toward you and looking at your mouth (reading lips)
What is nonverbal body language?
400
This is a quantitative measurement to assess visual acuity.
What is the Snellen Eye Chart?
400
This is the perception of sound when no actual external noise is present; it is commonly referred to as "ringing in the ears"
What is tinnitus?
400
Name this staging.
What is DTI (deep tissue injury)?
500
These two vascular lesions: one are tiny, pinpoint hemorrhages caused by superficial bleeding from the capillaries of the skin; measure less than 3mm may be related to platelet deficiencies. The other is a hemorrhagic red or purple spot or rash that is flat and does not blanch; measures 3-10mm, may be associated with platelet disorders.
What are petechiae and purpura?
500
This cranial nerve assess symmetry of the face.
What is cranial nerve VII? (facial)
(nasolabial folds: the distance from the corner of each nostril to the corner of the lip bilaterally should be equal. & Palperbral fissures; distance between the upper and lower eyelids)
500
This test is used to assess for impaired or high-frequency hearing loss.
What is the whispered voice test?
500
Distant objects appear blurred because the visual image becomes focused in front of the retinal instead of on the retina.
What is Nearsightedness (myopia)?
500
According to American Diabetes Association; patients who have genetic disposition of diabetes are at greater risk for developing these eye disorders.. (4 disorders)
What are retinopathy, blindness, glaucoma, and cataracts?
500
Stage this wound..
What is stage 1?
600
You would best assess color change in the conjunctiva, palm of hands, and mucous membranes for this person...
What is dark pigmented skin tone?
600
Lips inverted, swelling, erythema, lesions, cracking of skin are what kind of findings?
What are abnormal assessment findings of the lips?
(angioedema is edema of the lips usually related to an allergic reaction)
600
These are the two most common complaints in which someone would seek medical care..
What are otalgia (ear pain) and otorrhea (ear drainage)?
600
This chart is used to determine if a patient has difficulty reading.
What is the tumbling "E" chart?
600
This diet rich in fruits and vegetables, particularly dark leafy greens (spinach, kale, collard greens), and eating fish high in omega-3 fatty acids are important for which organ.
What is an eye healthy diet? (Eat right to protect your sight)
600
This force is a sliding movement of skin and subcutaneous tissue while the underlying muscle and bone are stationary.
What is shearing?
700
This is excessive growth of thick, dark hair in women where normally the hair does not grow, including areas as face, chest, abdomen, arms, and legs. Usually caused by abnormality of androgen production (testosterone), metabolism, medications, or hormonal therapies..
What is Hirsutism?
700
This cranial nerve assesses position of the tongue.
What is the hypoglossal nerve or cranial nerve XII?
700
If you answer "yes" to how many questions on the "Do you need a hearing test?" should you seek a consult from an otolaryngologist or and audiologist for hearing evaluation..
What are 3 or more "yes" answers?
700
This is a sign of elevated bilirubin in the blood; occurs with patients who have liver disease.
What is scleral jaundice (icterus)?
700
This is one of the largest and heaviest organs of the body.
What is the skin?
700
Stage this pressure ulcer..
What is stage 3?
800
The following are all examples of :
Macule (freckle), Patch (Mongolian spot), Papule (mole), plaque (psoriasis), vesicle (herpes simplex), nodule, tumor, wheal (hives), cyst...
What are primary skin lesions?
800
Fall prevention, car safety, and recreational safety are patient education topics to prevent this...
What is TBI? (traumatic brain injury)
800
This test is used to assess unilateral hearing loss and functioning of the cochlear nerve (CN VIII).
What is the Weber Test?
800
Inspect the eye, Assess: Visual acuity, color blindness, central vision, peripheral vision, ocular motility, accommodation, pupil size/consensual response, and internal structures.
What is the sequence of an Eye Assessment?
800
This is the ideal recommendation from American Academy of Dermatology to prevent sun damage.
What is sunblock with SPF 30 and water resistant?
800
Stage this pressure injury.
What is unstageable?