Follow the Cues Assessment
The nurse hears an extra heart sound immediately after S2. This is the heart sound being heard.
What is S3?
A patient’s tonsils are visible but do not extend beyond the pillars. This tonsil grade is considered normal.
What is 1+?
This is used to test visual acuity.
What is the Snellen Chart?
This is how the nurse should palpate the carotid artery.
What is one side at a time?
The part of the cardiac cycle when the ventricles relax and fill with blood.
What is diastole?
When assessing the carotid arteries, the nurse should do this one side at a time to avoid decreasing cerebral blood flow.
What is palpate the carotid pulse?
During the eye exam, both pupils constrict when light is directed into one eye. This expected response should be documented this way.
What is direct and consensual light reflexes intact?
This test is used to assess hearing acuity.
What is the whispered voice test?
Symptoms of this disorder can include goiter, tachycardia, exophthalmos, weight loss, and warm moist skin.
What is Grave's Disease (hyperthyroidism)?
A gentle blowing or swooshing sound that can be heard on the chest wall.
What is a murmur?
A patient has jugular venous distention while positioned at 45 degrees. This finding suggests increased pressure on this side of the heart.
What is the right side?
An older adult has a gray-white ring around the edge of the cornea with no change in vision.
What is arcus senilis?
Thick, raised, white patches on the tongue from recent antibiotic use.
What is candidiasis (yeast)?
The term for the two areas of the infant's skull that allow for brain growth during the first year.
What are "soft spots" or fontanels?
What are obesity, smoking, high blood pressure, high cholesterol, diabetes, sedentary lifestyle, smoking, and stress?
The nurse hears a blowing sound over the carotid artery with the bell of the stethoscope. This finding should be documented as this.
What is a carotid bruit?
A patient reports sudden flashes of light, new floaters, and a “curtain” over part of the visual field. This finding requires urgent evaluation for this condition.
What is retinal detachment?
This is what is being assessed when having a client follow the penlight with their eyes in the following directions: up/right, right, down/right, down/left, left, and up/left.
What are the six cardinal positions of gaze?
This is the side of the stethoscope that you would use to assess a carotid bruit.
What is the bell?
Heart failure on this side of the heart has symptoms of jugular vein distention, edema, and ascites.
What is right-sided heart failure?
A patient has JVD, dependent edema, hepatomegaly, and recent weight gain. These clustered assessment findings point to this problem.
What is right-sided heart failure/systemic venous congestion?
A patient has unilateral facial drooping. The forehead is spared, and the patient can wrinkle both sides of the forehead. This finding should make the nurse suspect this rather than Bell palsy.
What is a central neurologic lesion/stroke?
The expected palpable characteristics of normal cervical lymph nodes.
What is mobile, soft, and nontender?
The expected palpable characteristics of normal cervical lymph nodes.
What is mobile, soft, and nontender?
What is left-sided heart failure?