Vital Signs
Normal adult bp range?
What is: 120/80
Things that worsen symptoms
What are: Aggravating Factors
Documentation abbreviation for no allergies
What is: NKDA
To create a non-threatening and relaxed atmosphere how should you greet the pt?
What is: Greet them with a smile by their first name (welcoming vibe)
Excessive sweating
What is: diaphoresis
List the 4 VS indicators
What is: 1. Temperature 2. Respiration 3. Blood Pressure 4. Pulse
The pt says "The pain starts in my lower back and travels down my leg" Which component is this?
What is: Radiation
The pt denies smoking, but takes marijuana gummies, where would this go in the pt chart?
What is: Social History
The provider wants to perform a Pap smear; name the position you would place the pt in
what is: Lithotomy
The contraction phase of the heartbeat is:
What is: Systole
Temperature routes
What are: Oral (O), Axillary (AX), Temporal (TA), Tympanic (AU), & Rectal (R)
6-7 Observable signs of hypotension
What is: Dizziness, headache, vomiting, fainting, confusion, pale skin, & fatigue
Which feedback technique involves briefly repeating back the exact information back to the speaker?
What is: Restatement
Pt's oral temperature is 102.4 deg F. Describe first steps
What is: Ask pt how they are feeling (assess pt overall condition) & notify provider
Examination technique that uses stethoscope
What is: Auscultation
During VS you notice the pt does not have a steady heart rhythm. This is called:
What is: Arrhythmia
The pt is rating their pain 9/10 but is not showing any physical signs. How would you document their pain?
What is: Document what they are saying, and note the lack of physical signs. Let the provider know your observations.
When a mistake is made in the pt's physical chart, how would you correct it?
What is: Strike through the mistake with a line, initial, and write the correction next to it.
The pt becomes verbally aggressive during the respirations measurement portion of VS, stating "Why are you staring at me, weirdo???" What do you do?
What is: Calmly let them know what you are doing; apologize if you made them uncomfortable
Difference between Myopia & Hyperopia
What is: Nearsightedness vs. Farsightedness
List the 7 different Pulse Sites
What is: Radial, Brachial, Apical, Carotid, Femoral, Dorsal Pedalis, Popliteal
Describe Follow-up questions and Add Assessment Note-
CC: "I've had severe sharp pain in my lower abdomen on the right side since last night; it gets worse when I move."
What is: "Have you taken any medications to help with the pain?"
"How would you describe the pain?"
"When was your last bowel movement?"
"RLQ severe pain; onset 12 hrs ago; worsens with movement"
What is: Substance use, work exposure risk, & length of hazardous occupation exposure
Pt comes in complaining of abd pain. You need to look for signs of swelling, listen for bowel sounds, and feel the abd for abnormalities. Name 3 examination techniques the provider would use
What is: 1. Visual Inspection 2. Auscultation 3. Palpation
Meaning for abbreviations: OS, OU, & OD
What is: Left eye, Both eyes, & Right eye