General
This type of assessment is an in-depth assessment of the whole person, including physical, mental, emotional, cultural, and spiritual aspects of a patient’s health
Comprehensive Assessment
A patient has bad breath. This is called ______.
Halitosis
Continuous, melodious, musical, or whistling breath sounds due to constriction of the airway
Wheezing
A patient has 45 clicks/gurgles per minute upon auscultation in all 4 quadrants. What could be the cause of this finding?
Diarrhea, IBS, Infection, Laxative Use
PERRLA stands for:
Pupils equal, round, reactive to light and accommodation
What are the six techniques for physical assessment
Interview, Inspection, Palpation, Percussion, Auscultation, Olfaction
A patient has an eyelid droop. This is called:
Ptosis
This is the name for abnormal breath sounds
Adventitious
A person that continually has sordes is at risk for what complication
Pneumonia
A patient has 20/50 vision. What does this mean?
What the average person can see clearly at 50 feet away the patient can see at 20 feet
- When patient condition changes
- Gut feeling something is wrong
- Evaluating interventions
- Beginning of each shift
- On admission
Anisocoria
Crackling, popping breath sounds caused by air moving over secretions or alveoli opening up; they can be fine or coarse and do not clear with coughing
Crackles
A patient with JVD could be showing signs of :
Right sided heart failure
A patient's right pupil constricts when a light shines in it and the left pupil constricts as well. This is called:
Consensual reflex
What are the components of a pain assessment
Onset
Location
Duration
Characteristics
Aggrevating
Relieving
Timing
Severity
A patient is having trouble breathing and instead of his chest rising when breathing it sinks inward. This is called:
Retractions
Breath sounds that may sound like soft snoring, rattling, gurgling, or low-pitched wheezes; may clear with coughing;
Rhonchi
A patient that is nearing death is likely to have what type of respirations?
Cheyne-Stokes
When focusing on a far away object, both of the patient's pupils dilate. This is called:
Accommodation response
What are the six vital signs and their normal values
T: 36-38C
Pulse ox- 95%-100%
RR- 12-20 bpm
Pulse 60-100 bpm
BP: <120/<80
Pain: hopefully 0
A patient complains of numbness and tingling in the lower extremities. The nurse documents that the patient is experiencing:
Paresthesia
This lung sound is a life threatening emergency which may indicate a foreign body lodged in the airway
Stridor
What are the possible causes of atelectasis?
Pneumonia and lung collapse
This is the name of the chart that test for visual acuity
Snellen chart