Heart
Where is the PMI located?
5th intracostal space, midclavicular line
Increased fremitus could indicate what?
Pneumonia
What is the name of the chart to check visual acuity?
Snellen chart
What does ABCDE stand for when assessing a skin lesion?
Asymmetry, Border irregular, Color variations, Diameter >6mm, Evolving
How to assess the inner canal of an adults ear?
Pull out, back and up.
How do you check for pulse deficit?
Listen to apical pulse while palpating radial pulse for 1 minute.
The nurse is auscultating the chest, what would be a normal finding and what would abnormal?
Vesicular breath sounds. Adventitious breath sounds.
The right pupil reacts to light when light is directed into the left eye. This is called?
Consensual response
What is a normal CRT?
Less than 3 seconds.
How do you perform Weber test and what is it checking for?
Tuning fork is activated and place on patients head. Ask the patient where they hear the noise. bone conduction and sensorineural disturbance.
What are increased risk factors for heart disease?
Obesity, not exercising multiple times per week, smoking, hyperlipemia, HTN, High stress, Alcohol abuse
What is the normal anteroposterior to transverse diameter of the chest?
Ratio of 1:2
What does PERRLA stand for?
Pupils, Equal, Round, Reactive, (to) Light, Accommodation
What can clubbing of the nails indicate?
Long term lack of oxygen
Name what the nurse should assess when assessing nails?
Contour of nail, texture, color, is nail bed intact, surrounding tissue
Pulse locations: Pedal(Dorsalis pedis), popliteal, posterior popliteal
Top of foot, posterior knee, Inner ankle
What is a high-pitched, musical type sound that are best heard on expiration?
Wheezes
What questions are important to ask in regards to eyes?
Last eye exam, eye disease, injury, surgery, DM, HTN, blood dyscrasia, current use of eye medications, glasses, changes in vision, itching, pain.
What is the proper way to assess and chart for edema?
Location, temperature, pitting or non-pitting. 1+, 2+, 3+, 4+
Name three things assessed that pertain to the neck.
ROM (Muscles), Strength, Symmetry, Lymph nodes, Trachea
The nurse is listening to heart sounds and hears Lub-dub. What are these sounds called?
S1 and S2
When processing over the lung fields what would a normal finding?
Resonant sound (low pitched, hallow sound)
Stand directly in front of patient, patient holds head fixed. Move the penlight or finger through the six cardinal fields of gaze.
When testing skin turgor, the skin remains tented and moves back slowly. What could this mean?
Dehyration
Name abnormal findings of the mouth
Pallor, dry, blisters, leukoplakia, bleeding, ulcerations, missing teeth, gum edema, bony growths, discharge, enlarged tonsils