General, vitals, skin, psychosocial
Are the following findings normal or abnormal and what body system/assessment category do they belong to? Poor hygiene and slumped posture.
What is abnormal and general survey?
Your patient is admitted to the floor and noted to have dry mucous membranes and grey in color. Is this considered normal or abnormal? If abnormal what is the normal assessment findings?
What is abnormal? Should be moist and pink.
A patient has a capillary refill of less than 2 seconds, a regular heart rate and rhythm, and no edema. Is this a normal or abnormal cardiovascular assessment?
What is normal?
True or False: You only have to listen to bowel sounds in the upper right and left quadrants.
A patient has just woken up from surgery. You are assessing for orientation. The patient tells you their name and birthday. They say the year is 2020 and the month is May. They answer they are in the hospital but they do not know why they are in the hospital or what happened. How would you document this?
What is alert and oriented x2?
A patient presents with skin that is warm, dry, pink, and intact. Is this a normal or abnormal finding?
What is normal?
You are reading a head to toe assessment from the previous shift. Written next to eyes is PERRLA. Is this normal or abnormal and what does it stand for?
What is normal? Pupils are equal, round, reactive to light, and accommodation
A patient is going for an MRI. They are known to be claustrophobic. Their respirations are 26 breaths/min, they are sweating and fidgeting. Is this normal or abnormal? What should we do next?
True or False: Bowel sounds are considered absent if you listen in 1 quadrant for 1 minute and hear no sounds.
What is false? You must listen for at least 3-5 minutes in each quadrant before documenting absent bowel sounds.
Describe abnormal musculoskeletal assessment findings?
What is weakness, limited ROM, swelling, pain, unsteady gait, contractures, and deformities?
A patient is currently in the hospital with the following vital signs: Blood pressure 122/78, pulse of 105, oral temp of 99.8 F, respiration rate of 17, and oxygen saturation of 92% on RA. Are these vitals abnormal or normal? If abnormal please give the normal ranges.
What is abnormal? Blood pressure should be less than 120/80 so the systolic is abnormal, pulse should be between 60-100 beats/min, temp should be between 98.0-98.6 F oral, and oxygen saturation should be above 95% (could still be considered normal as long as it is over 90%). Respirations are normal and the range is 12-20 breaths/min
A child is brought to the ER by his mother and found to have purulent drainage from his left ear. Is this considered normal or abnormal? And what does purulent drainage mean?
What is abnormal? And purulent drainage is pus like drainage (can be thick yellow/green, typically means some sort of infection)
You come upon a patient who is having difficulty breathing. You notice shallow breaths and the use of accessory muscles. Their respirations are 32 breaths/min. Is this normal or abnormal? If abnormal, what is a normal assessment?
What is abnormal? Respirations should be between 12-20 breaths per minutes. Respirations should be even and unlabored.
A patient has voided 30 mL of urine in the last 6 hours. Is this normal or abnormal?
What is abnormal? A patient should produce at least 30 mL of urine per hour.
Are the following findings normal or abnormal and what body system/assessment category do they belong to? Disoriented, slurred speech, facial drooping, and unequal grip strength.
What is abnormal? Neuro
A patient comes into the office and you notice they seem to be talking to themselves, becoming agitated, and avoiding eye contact. Is this a normal or abnormal finding?
What is abnormal?
What are abnormal assessment findings related to the nose?
What is epistaxis (nose bleed), congestion, nasal flaring, purulent drainage, tenderness, polyps, deviated septum, dry mucosa?
Describe abnormal cardiovascular assessment findings?
What is irregular rhythm, extra heart sounds (murmurs), weak pulse, edema, jugular vein distention, and capillary refill greater than 3 seconds.
An older adult female presents with acute confusion, urinary incontinence (she is typically continent), and her urine is cloudy, foul smelling, and red/dark brown in color. Is this considered normal or abnormal? If abnormal what could this be a sign of?
What is abnormal and UTI?
A patient is doing physical therapy. They are assessing range of motion. The patient is unable to turn their neck to the right or put their neck to their chest. The physical therapist documents full range of motion in the neck. Is this correct or incorrect?
What is incorrect? This would be considered limited range of motion in the neck.
A patient has just returned from leg surgery. The skin of his foot cold and blue in color. His pedal pulse is also absent. Is this normal or abnormal and what should you do next?
What is abnormal? And notify the physician immediately.
A patient returns from a thyroidectomy. You are going in for your next assessment and notice the patient is having trouble breathing and you hear a crowing like sound when the patient inhales. What abnormal assessment finding would this be? And what would your next step be?
What is tracheal deviation? Call for rapid response because this is an EMERGENCY!
Describe the following types of adventitious breath sounds: crackles, rhonchi, wheezes, and stridor?
What is?
Crackles: popping, crackling, or bubbling sounds. May be fine or course
Rhonchi: low pitched, snoring, gurgling sound
Wheezes: high pitched, musical, squeaky sound
Stridor: loud, harsh, high pitched crowing sound
A patient is found to have absent bowel sounds. His abdomen is distended and hard. Is this abnormal or normal, what could this be a sign of, and what would you next step be?
What is abnormal, bowel obstruction, and call the provider ASAP.
A patient who had surgery earlier this morning presses their call light saying they can't grip with their left hand and their left leg isn't wanting to move. You notice they are slurring their speak as well. Is this normal or abnormal? What to you suspect? And what is your next step?
What is abnormal? Stroke or clot. Call for rapid response and notify provider immediately.