Vital Signs
What are the normal ranges for adult blood pressure, heart rate, and respiratory rate?
BP: 120/80 mmHg, HR: 60-100 bpm, RR: 12-20 breaths/min
What are the four main components of the general survey?
Physical appearance, body structure, mobility, and behavior
Where is the apical pulse located?
5th intercostal space, midclavicular line (PMI)
What does PERRLA stand for?
Pupils Equal, Round, Reactive to Light and Accommodation
What does "ROM" stand for in musculoskeletal assessment?
Range of Motion
Which artery is most commonly used to measure blood pressure manually?
Brachial artery
What does "alert and oriented x4" mean?
The patient is aware of person, place, time, and situation
What are normal heart sounds and what causes them?S1
S1 (lub) - closure of mitral & tricuspid valves; S2 (dub) - closure of aortic & pulmonic valves
What are the five components of a basic neurological exam?
Mental status, cranial nerves, motor function, sensory function, reflexes
How do you assess for scoliosis?
Have patient bend forward; look for asymmetry in shoulders or spine
What are the five vital signs?
Temperature, Pulse, Respirations, Blood Pressure, and Pain
What is the best way to document subjective data?
Using the patient’s exact words in quotation marks
What are crackles in lung sounds associated with?
Fluid in alveoli, seen in pneumonia, heart failure, or pulmonary edema
How do you assess the Glasgow Coma Scale?
Measures eye-opening, verbal response, and motor response (score 3-15)
What does a "stage 2 pressure ulcer" look like?
Partial-thickness skin loss, may present as a shallow open ulcer or blister
How do you assess a patient's radial pulse?
Use the index and middle fingers, count for 60 seconds
What does SOAP stand for in documentation?
Subjective, Objective, Assessment, Plan
What is the significance of checking capillary refill?
Assesses peripheral circulation; should be <2 seconds
How do you check for cerebellar function?
Tests balance and coordination, e.g., Romberg test, finger-to-nose test
What does the ABCDE rule assess in a skin exam?
Asymmetry, Border irregularity, Color variation, Diameter >6mm, Evolution
Define orthostatic hypotension and how to assess for it.
A drop in BP of 20 mmHg systolic or 10 mmHg diastolic when moving from lying to standing; assess by measuring BP in different positions
Define SBAR and when it is used.
Situation, Background, Assessment, Recommendation - used for nurse-to-nurse or nurse-to-provider communication
What is the best position to auscultate abnormal lung sounds?
Sitting upright, patient taking deep breaths through an open mouth
What is the Babinski reflex and what does it indicate?
Toes fan out when the sole is stroked; normal in infants, abnormal in adults (suggests CNS damage)
What is the difference between passive and active ROM?
Passive: examiner moves the joint, Active: patient moves it themselves