PHYSICAL ASSESSMENT- A
Lowest score for GLASGOW COMA SCALE
3
Highest score: 15
Categories: eye opening, verbal response, motor response
Percussion Sound
Intestines & Stomach
TYMPANY
PERCUSSION SOUNDS
Flat- very soft, short, abrupt (bones)
Dull- short, high-pitched (liver, spleen, heart)
Tympany- loud, hollow sound (intestines, stomach)
Hyperresonance- louder than tympany (lungs)
What should you instruct to your patient when inserting a chest tube?
INHALE DEEPLY
T or F?
Hand veins in the dominant hand are preferable for IV insertion in children.
F
Hand veins in the nondominant hand are preferable for IV insertion in children.
A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium has a prothrombin time (PT) of 50 seconds. On the basis of these laboratory values, the nurse anticipates which prescription?
A. Adding a dose of heparin sodium
B. Holding the next dose of warfarin
C. Increasing the next dose of warfarin
D. Administering the next dose of warfarin
B
The normal PT is 11 to 12.5 seconds (conventional therapy and SI units). A therapeutic PT level is 1.5 to 2 times higher than the normal level. Because the value of 50 seconds is high, the nurse should anticipate that the client would not receive further doses at this time. Therefore, the prescriptions noted in the remaining options are incorrect.
Positive Phalen's test is indicative of ___________________.
CARPAL TUNNEL SYNDROME
What sign for meningitis is being described below?
Have the client lie supine with one leg flexed. Tell him to extend the leg while you apply pressure to the knee
Contraction and pain of the hamstring muscles and resistance to extension indicates meningitis
KERNIG'S SIGN
KERNIG’S SIGN
Have the client lie supine with one leg flexed. Tell him to extend the leg while you apply pressure to the knee
Contraction and pain of the hamstring muscles and resistance to extension are positive signs of meningitis
BRUDZINSKI’S SIGN
Have the client lie supine with his head flexed to his chest
Flexion of the hips with flexion of the head is a positive sign of meningitis
What should you instruct to your patient when removing a chest tube?
Exhale & bear down (Valsalva maneuver)
T or F?
By repeating colostomy irrigation regularly — once every three days — the colon can be trained to empty with no spillage of waste in between irrigation
F
By repeating colostomy irrigation regularly — once a day or every other day — the colon can be trained to empty with no spillage of waste in between irrigation
HBA1C: 10%
HIGH
Nondiabetic adult: 4-5.9%
Good diabetic control: <7%
T or F?
Bowel sounds of more than 20 clicks/ minute may IBD, bowel infection, early bowel obstruction, diarrhea, resolving paralytic ileus, laxative use
F
Absent: no BS for 5 min.
Hypoactive: less than 5 per minute
Active: 5-30 per minute
Hyperactive: more than 30 per minute
_____________ is the ability to recognize the form of solid objects by touch
STEREOGNOSIS
Ability to recognize the form of solid objects by touch
PROCEDURE
With client’s eyes closed, place a familiar object, such as a coin or a button, in client’s hand, and ask client to identify it
Test both hands using different objects
NORMAL FINDINGS
Stereognosis intact bilaterally
ABNORMAL FINDINGS
Client is not able to identify the objects
T or F?
Ear irrigation is indicated for patients with vegetable foreign body (like peas, corn kernel, beans)
F
Ear irrigation is contraindicated for patients with vegetable foreign body (like peas, corn kernel, beans), because vegetables absorb moisture and may swell
Fluctuations (tidaling) in the water seal chamber during inhalation and exhalation is normal.
T
Also, excessive or constant bubbling in the water seal chamber indicates air leak
L, N, H?
Urine specific gravity: 1.5
HIGH
Urine specific gravity- 1.010 to 1.030
T or F?
Arab Americans believe that it is unhealthy to mix hot and cold food
T
Cranial Nerve 1 : ?
OLFACTORY
Only One Of The Two Athletes Felt Very Good, Victorious, And Healthy
Ear assessment for 9 year old, how do you pull the pinna?
UP, BACK
CHILD (under 3): DOWN, BACK
ADULT (over 3): UP, BACK
T or F?
When instilling eye medications, the nurse should first clean the eye from outer to inner canthus.
F
When instilling eye medications, the nurse should first clean the eye from inner to outer canthus.
L, N, H?
Serum Calcium: 15 mg/dL
HIGH
Normal serum Calcium: 8.5 to 10.2 mg/dL
_____________ is bluish discoloration around the umbilicus which may indicate pancreatitis or intraperitoneal bleeding.
Cullen’s sign (bluish discoloration around umbilicus): hemorrhagic pancreatitis or intraperitoneal bleeding
Grey- Turner’s sign (discoloration of lower abdominal flanks and lower back): pancreatitis or extra-peritoneal bleeding
___________ discontinuous sounds resulting from air bubbling through moisture in the alveoli or from collapsed alveoli
CRACKLES
WHEEZES: continuous sounds caused by narrowing of an airway by spasm, inflammation, mucus secretion, or solid tumor
STRIDOR: harsh, high- pitched, continuous, honking sound resulting from an upper airway obstruction, a partial obstruction, or spasm of the trachea or larynx
RALES/ CRACKLES: discontinuous sounds resulting from air bubbling through moisture in the alveoli or from collapsed alveoli
FRICTION RUB: occurs in the pleural layers, not in the lungs; results from rubbing together of the parietal and visceral layers of an inflamed pleura
T or F?
The water seal chamber usually contains 20cm of water and should be maintained at this level to maintain negative pressure.
F
The water seal chamber usually contains 2cm of water and should be maintained at this level to maintain negative pressure.
You're assessing a patient who is post-opt from a chest tube insertion. On assessment, you note there is 50 cc of serosanguinous fluid in the drainage chamber, fluctuation of water in the water seal chamber when the patient breathes in and out, and bubbling in the suction control chamber. Which of the following is the most appropriate nursing intervention?
A. Document your findings as normal.
B. Assess for an air leak due to bubbling noted in the suction chamber.
C. Notify the physician about the drainage.
D. Milk the tubing to ensure patency of the tubes.
A
L, N, H?
Arterial Blood Gas (ABG) pH: 7.29
LOW
Arterial Blood Gas (ABG) pH: 7.35 to 7.45