Assessment Landmarks
This landmark located at the 2nd intercostal space, right sternal border, is used for auscultating which heart valve?
What is the aortic valve?
Cranial Nerve responsible for smell
CNI Olfactory
This normal finding describes pupils that are equal, round, reactive to light, and accommodating.
What is PERRLA?
This term refers to the normal breath sound heard over most lung fields.
What is vesicular breath sounds?
Pain from appendicitis classically begins as vague periumbilical discomfort before localizing to this right‑lower‑quadrant point.
What is McBurney’s point?
This heart sound is created by closure of the AV valves and marks the beginning of systole.
What is S1?
According to Piaget, children ages 2–7 are in this stage of cognitive development, where symbolic thinking grows but logical reasoning is limited.
What is the preoperational stage?
This measurement is routinely taken at every well‑child visit during the first 2 years of life to assess brain growth.
What is head circumference?
Sequence of abdominal assessment
Inspection, auscultation, percussion, palpation
Cranial nerve responsible for taste: salt & sugar
Facial Nerve (VII)
This cranial nerve is tested by asking the patient to smile, puff cheeks, or raise eyebrows.
What is Cranial Nerve VII (Facial)?
These abnormal breath sounds are caused by air moving through fluid in the alveoli, often heard in pneumonia or heart failure.
What are crackles?
Costovertebral angle tenderness on percussion during GU assessment suggests inflammation of this organ.
What are the kidneys?
A systematic process of collecting, validating, and communicating patient data that forms the foundation of nursing care.
Health Assessment
Adolescents develop the ability to think abstractly and understand hypothetical situations during this Piagetian stage.
What is the formal operational stage?
When assessing an older adult, sudden changes in mental status should prompt evaluation for infection, most commonly this type.
What is a urinary tract infection (UTI)?
Cardiac landmark located at the apex of the heart
Mitral Valve
Cranial nerve responsible for voice phonation and swallowing.
Vagus Nerve (CNX)
This test evaluates extraocular eye movements by tracing a star or “H” pattern.
What is the six cardinal positions of gaze test or Accomodation?
This respiratory pattern is characterized by progressively deeper and faster breathing followed by periods of apnea, often associated with brain injury or heart failure.
What is Cheyne–Stokes respiration?
A positive Murphy’s sign, gallbladder wall thickening, and pericholecystic fluid on ultrasound confirm this condition.
What is acute cholecystitis?
This bluish/grayish discoloration and downward curvature of the nail beds suggest chronic inadequate oxygenation.
What is cyanosis and clubbing?
This reflex causes a newborn to turn their head toward a gentle touch on the cheek and begin sucking motions.
What is the rooting reflex?
This early childhood respiratory assessment finding—retractions above or below the ribs—suggests increased work of breathing.
What are intercostal or suprasternal retractions?
This vertical and horizontal landmark intersection divides the abdomen into four quadrants.
What are the midline and the umbilicus (transverse line)?
Cranial nerves that are classified as sensory
I Olfactory
II Optic
VIII Acoustic
This test screens for hearing loss by placing a vibrating tuning fork on the mid‑forehead.
What is the Weber test?
A high‑pitched, musical, inspiratory sound caused by upper airway obstruction, requiring immediate assessment.
What is stridor?
This common condition in men over 50 leads to urinary hesitancy and nocturia due to enlargement of the prostate gland.
What is benign prostatic hyperplasia (BPH)?
Based on Maslow’s Hierarchy of Human Needs, this need is #1 priority.
Physiological Needs
This reflex is elicited when the infant’s palm is touched, causing them to close their fingers around the examiner’s finger.
What is the palmar grasp reflex?
Pregnant individuals are screened for this condition between 24–28 weeks gestation using a glucose tolerance test.
What is gestational diabetes?
This posterior thoracic landmark at the level of T10 marks the lower border of the lungs during normal respiration.
What is the inferior lung base?
Cranial Nerves that are classified as Motor
III Oculomotor
IV Trochlear
VI Abducens
XI Spinal Accessory
XII Hypoglossal
This visual acuity chart is commonly used to assess central vision from 20 feet away.
What is the Snellen chart?
This finding occurs when air escapes into the subcutaneous tissue, creating a crackling sensation upon palpation.
What is subcutaneous emphysema?
This kidney filtration marker is often elevated in renal failure and is measured alongside creatinine to estimate GFR.
What is blood urea nitrogen (BUN)?
Percussion Sound heard over areas of enclosed air (air in bowel)
Tympany
This reversible cause of confusion in older adults is often triggered by infection, medications, or metabolic changes.
What is delirium?
This normal finding in infants causes their abdomen to appear round and protruding when they are standing.
What is a toddler/preschooler abdominal protuberance?
The Apex of the Heart is normally located at this intercostal space and anatomical line.
What is the 5th intercostal space, left midclavicular line?
Cranial classified as both sensory and motor
V Trigeminal
VII Facial
IX Glossopharyngeal
X Vagus
When examining the ear, pulling the pinna up and back helps straighten this structure for better visualization.
What is the ear canal?
This technique involves tapping on the thorax to assess underlying tissue density, helping identify consolidation or hyperinflation.
What is percussion?
During a female GU exam, cervical motion tenderness on bimanual palpation suggests this potentially serious infection.
What is pelvic inflammatory disease (PID)?
This type of skin lesion is elevated, circumscribed, and fluid‑filled, and is commonly seen with herpes infections or chickenpox.
What is a vesicle?
This term describes the age‑related decrease in the ability of the lens of the eye to focus on close objects.
What is presbyopia?
During a middle‑adult health assessment, providers routinely screen for this condition using blood pressure, BMI, and lifestyle history due to rising cardiovascular risk.
What is hypertension?