Look what I found!
This is detected best through palpation with the back of the hand in a very dark skinned person
What is erythema?
This rating is assigned when muscle strength is full resistance to the examiner's push
What is 5/5?
Condition that requires repositioning client every 2 hours
What is immobility?
Pressing on the nail bed to detect when blood returns
What is capillary refill time?
Indication of severe respiratory distress that affects ability to communicate.
What is "three word dyspnea"?
This is the simultaneous response in both pupils to light
What is consensual reaction?
Along with sticky mucous membranes and decreased urine output, this skin finding indicates dehydration.
What is poor turgor?
Important to promote breast awareness and detect early changes
What is self-breast exam?
The second step in abdominal assessment
What is auscultation?
Sudden change or loss of this sense is a serious concern
What is vision?
Grade for edema that depresses to 4 mm and rebounds in 10-20 seconds.
What is 2+?
This sound may be heard when decreased pulse intensity is felt over the carotid
What is a bruit?
Vaccines that prevent sexually transmitted infections
What are Hepatitis A, Hepatitis B, and Human Papillomavirus?
Request the client to do this to verify presence of rhonchi
What is cough?
Damage to this cranial nerve causes dysphagia
What is CN IX (glossopharyngeal nerve)?
Grade for tonsils that are touching when assessing the nasopharynx
What is 4+?
Assessment findings for this condition include pale conjunctivae and "spooning" fingernails
What is anemia?
Colonoscopy
What is an important diagnostic procedure to detect early colorectal cancer?
Structure heard at the 2nd intercostal space on the left sternal border
What is the pulmonic valve?
The first sign of impaired cerebral function
What is decreased level of consciousness?
Watching for unsteadiness or imbalance with walking
What is gait assessment?
This auscultation finding might be heard with a collapsed lung
What is absent or decreased breath sounds?
Important subjective information related to pinpointing cause of continued HTN after medication is prescribed.
What is compliance?
Suspected condition when bulge occurs in groin area
What is an inguinal hernia?
This results in a Glasgow coma scale score of 3
What is severely decreased level of consciousness?