Neurological Assessment
This test requires a pen light to complete this part of a neuro assessment.
What is PERRLA?
These are 3 signs of normal respiratory status.
What is: rate 12-20, normal depth, regular rhythm, clear lung sounds, able to talk w/o difficulty etc.
Three things to assess during inspection of the abdomen.
What are color, contour, symmetry, distention, abnormal venous patterns etc?
Are 3 assessments to monitor peripheral perfusion.
What are edema, color, temperature, capillary refill, pulses?
Two things you MUST do going in and out of a client's room.
What is hand hygiene and provide safety (lower the bed and give call light)?
This assessment procedure involves pinching the skin between two fingers and holding it up for a few seconds and releasing. The best place to assess this is at the collar bone.
What is Skin Turgor?
These 4 things are used to check a person's level of consciousness (LOC).
What is person, place, time and event?
The skin of the chest pulls inward making the ribs prominent when a person inhales and is a sign of respiratory distress.
What is intercostal retractions?
The order of assessment steps (inspection etc.) for an abdominal assessment.
What is inspection, auscultation, palpation and percussion?
This test assesses peripheral perfusion by squeezing the tips of the fingers and seeing how long until a pink color returns to the tips.
What is capillary refill? (what is a normal capillary refill?)
A typical way to assess pain on an alert and oriented adult.
What is the pain scale?
Prior to doing an abdominal assessment or pelvic exam, the nurse should assist the client to...
What is to void or use the restroom?
This test is given over specified times to check on the neuro status. Generally it's given to stroke patients
What is the NIH stroke scale.
Are the places of the lungs that a nurse should auscultate for level 1 students?
What is 4 anterior, 6 posterior, and 1 lateral? (demonstrate)
Abdominal sounds or gurgles 5-30 per minute
What is normal abdominal sounds?
When listening to heart values, the nurse knows to use which part of the stethoscope?
What is the bell?
The pulses to assess lower extremities found on the ankle and food respectively.
What are the posterior tibial and dorsalis pedis?
In doing a respiratory assessment, if the nurse hears adventitious lung sounds, the nurse should instruct the client to...
What is take a deep breath and coough?
A Snellen chart, placed 20 feet away from the client measures...
What is Visual Acuity?
This abnormal breath sound is similar to the ruffling of tissue paper and is often due to consolidation or fluid in the lungs.
What are crackles?
The 4 areas of abdominal auscultation.
What are the RLQ, RUQ, LUQ, and LLQ?
This is the location where the apical pulse is heard best.
What is the 5th intercostal space, midclavicular line?
This test assesses balance by having a patient stand with feet together and hands by their side and then close their eyes for 20 seconds.
What is the Romberg Test?
Which of the following patients is the top priority?
1. A 25 year old with abdominal pain.
2. A stable 75 year old with COPD
3. A child with asthma who has stable VSs.
4. A 45 year old with acute confusion who is agitated and disoriented to place and time.
What is the 45 year old.
Having a patient focus on an object far away and then close is called...
What is accommodation?
This is measured by placing hands on the patient's back with thumbs toward the spine and watching for symmetrical movement when the patient breaths in.
What is chest expansion?
In order to chart that bowel sounds are absent the nurse must listen for a full _______ minutes.
What is five?
This pulse point is located behind and below the medial malleolus (ankle bone)
What is the tibial pulse?
This tool measures the amount of hemoglobin attached to red blood cells or the amount of oxygen in a person's blood.
What is a pulse ox?
When calculating the following, which formula is used?A nurse needs to infuse 100 ml over 2 hours, how should she set the pump?
ml/hr= ml per hour
100 ml/2 hrs= 50 ml per hour