Assessment

Question 1

Objective data-

Answer 1

facts, things that can be seen, felt, heard, & measured

Question 2

Subjective data-

Answer 2

patient feels or perceives

Question 3

Yellow nails-

Answer 3

pulmonary disease, thyroid disease, fungal infection

Question 4

White nails-

Answer 4

chronic renal failure, heart disease, diabetes

Question 5

Emphysema-

Answer 5

respiratory condition where lungs are over expanded with oxygen

Question 6

Unilateral dilated pupil-

Answer 6

ill nerve compression

Question 7

Bilateral dilated pupil-

Answer 7

midbrain injury; indication of drug use

Question 8

Irregular pupils-

Answer 8

orbital trauma

Question 9

Conjugate gaze deviation-

Answer 9

frontal lobe lesion

Question 10

Small/pinpoint-

Answer 10

pontine injury, opiate administration

Question 11

Dilation of eyes affected by-

Answer 11

drugs, oxygen to brain

Question 12

Levels of consciousness (6)-

Answer 12

-confusion
-Delirium
-lethargy
-obtundation
-stupor
-coma/comatose

Question 13

Confusion-

Answer 13

confused, disoriented, difficult to reason w/, don’t follow instructions, & may not be able to answer ?

Question 14

Delirium-

Answer 14

acute, confused state, pt. may be agitated or have hallucinations

Question 15

Lethargy-

Answer 15

severe drowsiness, often need gentle touch/stimulation to initiate response

Question 16

Obtundation-

Answer 16

need repeated stimulation to maintain attention & are slow to respond

Question 17

Stupor-

Answer 17

abnormal drowsiness & only responds to vigorous stimulation

Question 18

Coma/comatose-

Answer 18

pt. unresponsive to most or all stimuli

Question 19

2 ways to tell persons awareness-

Answer 19

Grady Coma Scale or Glasgow Coma Scale

Question 20

Signs of deteriorating LOC-

Answer 20

-lethargy, decreased pulse rate & respiratory rate
-immediately contact Dr. or radiologist
-may have to alter/postpone exam

Question 21

Hypovolemic-

Answer 21

caused by loss of blood or tissue fluid

Question 22

Normal respiration rate for adults-

Answer 22

12-20 breaths

Question 23

Children respiration rate-

Answer 23

20-30 breaths per minute

Question 24

Newborns respiration rate-

Answer 24

30-60 breaths per minute

Question 25

normal bp rate for adult-

Answer 25

120/80

Question 26

pre-hypertension-

Answer 26

120-140/80-89

Question 27

Stage 1 pre-hypertension-

Answer 27

140-141/90-91

Question 28

Stage 2 pre-hypertension-

Answer 28

160+/100+

Question 29

Hypotension-

Answer 29

BP reading less than 95/60

Question 30

normal resting pulse rate for an adult-

Answer 30

60-100 bpm

Question 31

normal resting pulse rate for a child-

Answer 31

70-120 bpm