Tissue Integrity & Nutrition
Skin lesion with characteristics that include elevated, palpable mass with serous fluid.
What is a vesicle or bulla?
Lung sounds heard at the outermost areas of the lung fields
What are vesicular lung sounds
BLE with cool, shiny skin
What is arterial insufficiency?
Part of the brain responsible for coordination
What is the cerebellum?
Epistaxis
What is bleeding from the nose?
The assessment tool used to assess skin breakdown
What is the braden scale?
What are fine crackles?
What is a murmur?
Neurological Assessment Tool scored 0-15
What is the Glasgow Coma Scale?
Described as ovoid, smooth, firm and rubbery
What are testes?
The "D" in an ABCDE skin assessment
What is diameter?
Respiratory pattern that is rapid, deep and labored
What is Kussmaul breathing?
The sound made when the AV valve closes
What is S1?
Inability to correctly identify object
What is astereognosis?
The evaluation of current and past health concerns that still impact the client
What is a review of systems?
Koilonychia
What are spoon shaped nails?
Often seen is iron deficiencies, endocrine or cardiac disease
Low-pitched grating sound during inspiration and expiration
What is a pleural friction rub?
The 5 points of heart sound auscultation
What is aortic, pulmonic, Erb's point, tricuspid & mitral
Awakens to vigorous shake or painful stimuli but returns to unresponsive sleep
What is stupor?
The motions of the hip joint
What is flexion, extension, hyperextension, circumduction, rotation, abduction and adduction?
Full thickness loss of skin with adipose tissue present
What is stage 3 pressure injury?
Tone found in majority of lung fields during percussion
What is dullness?
Secondary position used to palpate the apical impulse
What is left lateral?
Level of the spinal cord associated with patellar deep tendon reflex?
What is L2 to L4?
The four examination techniques
What is inspection, palpation, percussion & auscultation?