Assessment Tools
Mental Status Exam (MMSE) is used to assess?
Dementia
Before inserting an otoscope in an adult, what should the nurse do?
Pull pinna up and back
When taking a history, the client seems to take a lot of time before answering questions.
Should the nurse move on, rephrase the question, try to answer the question or allow the client time to answer?
Allow the client time to answer.....
What is decorticate posturing?
Upper extremities—flexion of arm, wrist, and fingers; adduction of arm (i.e., tight against thorax). Lower extremities—extension, internal rotation, plantar flexion. This indicates hemispheric lesion of cerebral cortex.
How would you ask or assess if someone smokes/uses tobacco products?
“have you ever or are you currently using tobacco products?”
Recall, Language, and Orientation are tested with what exam?
MMSE
What should the nurse do if unable to palpate pulses in lower extremities?
Use a doppler
What is it called when you have the client put both hands back to back while flexing the hands at a 90 degree angle?
What are you testing for?
Phalen Test
Carpal Tunnel
What is Decerebrate posturing?
Upper extremities stiffly extended, abducted; internal rotation, palms pronated. Lower extremities stiffly extended; plantar flexion; teeth clenched; hyperextended back. More ominous than decorticate rigidity; indicates lesion in brainstem at midbrain or upper pons
What method is used to assess skin lesions for possible skin cancer?
ABCD
If you want to be extra it is ABCDEF
Asymmetry (not regularly round or oval, two halves of lesion do not look the same)
Border irregularity (notching, scalloping, ragged edges, poorly defined margins)
Color variation (areas of brown, tan, black, blue, red, white, or combination)
Diameter greater than 6 mm (i.e., the size of a pencil eraser), although early melanomas may be diagnosed at a smaller size.
Elevation or Evolution
Funny looking (refers to the “ugly duckling” sign, in which the suspicious lesion stands out as looking different compared with its neighboring nevi.
When should domestic violence assessment be done?
As a routine part of the health history and assessment
What ROM do you assess for knees?
Flexion and extension
What finding is expected when you illicit a deep tendon reflex from the triceps?
Extension of forearm
How do you test Cranial Nerve VII
Ask the patient to smile, frown, close eyes tightly, lift eyebrows, show teeth and puff cheeks.
How do you test CN IX & X?
What are they called?
With the tongue blade elicits the gag reflex
What are signs of possible child abuse potentials?
Wariness of adults
Spiral fractures
Bruises on head in infants
What kind of ROM does a child need to jump rope?
Hint: Shoulder ROM
Circumduction
What is BEFAST & FAST?
Please tell me what each initial stands for.
What are you using this for?
BEFAST - Balance, Eye, Face, Arm, Speech, Time
FAST - Face Drooping, Arm weakness, Speech Difficulty and Time to call 911
Stroke
List all the tests a nurse can perform to test cerebellar function?
Rapid Alternating
Finger to nose
Heel to shin
Pg. 641
What is an example of Objective Data?
Temp 99.1
Crackles Bilaterally at bases
Alert and oriented X4
3+ Pitting Edema
What would you use the PHQ2 Tool for?
To assess for depression.
What grade (strength) would you give a client who can move extremity against partial resistance?
4+
•The MRC grading system:
•0, paralysis; 1, only a trace or flicker of muscle contraction is seen or felt;
•2, muscle movement is possible with gravity eliminated;
•3, muscle movement is possible against gravity;
•4, muscle strength is reduced, but movement against resistance is possible
• 5, normal strength.
Identify the different aspects or parts of the Glasgow Coma Scale?
Orientation
Eye opening
Verbal response
Best motor response
What is Nystagmus?
Severe shaking of the eye during cardinal fields test
What are the four main components of a mental status examination that a health care provider should address during a health history and physical exam?
Appearance, Behavior, Cognition, and Thought processes