Neurological Assessment
This test is used to test CN 3, 4, and 6 and requires a pen light.
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 to pass any validation.
What is hand hygiene and provide safety (lower the bed and give call light)?
These 3 things are used to check a person's level of consciousness (LOC).
What is person, place, and time?
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?)
The 6 parts to a pain assessment.
What is PQRSTU: provocative/palliative, quality, radiation, severity, time, understanding (how does the pain affect you and ADLs)? (plus location)
This cranial nerve is tested by puffing out the cheeks and lifting the eyebrows.
What is cranial nerve 7?
Are the places of the lungs that a nurse should auscultate. (demonstration)
What is 6-8 anterior, 6-8 posterior, and 1 lateral? (demonstrate)
The assessment for an ______ uses the bell of the stethoscope to listen for a whooshing sound.
What is an abdominal bruit?
This heart valve is located on the left sternal boarder, second intercostal space.
What is the pulmonic valve?
The pulses to assess lower extremities found on the ankle and food respectively.
What are the posterior tibial and dorsalis pedis?
This is elicited by striking the patellar tendon.
What is the patellar reflex?
This abnormal breath sound is similar to the ruffling of tissue paper and is often due to consolidation in the lungs.
What are crackles?
The 4 areas of auscultation.
What are the RLQ, RUQ, LUQ, and LLQ?
This is the location where the mitral valve is heard.
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?
A pen light is flashed in one eye and the other eye constricts as well. This reflex is called...
What is the consensual reflex?
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?
A nurse hears a bowel sound every 7 seconds. This is frequency is considered _________.
What is normal bowel sounds?
Are the valves closing in S1 and the valves closing in S2 respectively.
What is tricuspid and mitral (S1) and aortic and pulmonic (S2)?
This is the scale (with interpretation) used to assess strength.
What is
•0 = no voluntary contraction
•1 = contraction without movement
•2 = Full ROM, passive
•3 = Full ROM, active
•4 = Full ROM, against gravity, some resistance
•5 = Full ROM, against gravity, full resistance