💉- Assessment Test Flashcards
1
Q
What is a sign of pallor in light skinned patients and dark skinned patients
A
Light skinned - extreme paleness, skin appears white loss of pink or yellow tones
Dark skinned - loss of red tones
2
Q
Ashen
A
A blue-gray coloration of the skin also described as cyanosis
3
Q
What is Ecchymosis
A
Bruised (blue-green-yellow) area
4
Q
Petechiae
A
Tiny, pinpoint red or reddish-purple spots
Due to extravasation of blood into the skin
5
Q
Extravasation
A
Leakage from vessels
6
Q
Mottling
A
Bluish marbling splotchy
Sometimes seen in dying patients
7
Q
Name a type of embolus associated with petechiae
A
Fat
8
Q
What does trace mean in relation to pitting edema
A
Minimal depression with pressure
9
Q
What is the acronym used to assess skin lesions
A
A - asymmetry B - border irregularity C - color variation D - diameter E - elevation Patterns
10
Q
What is central cyanosis
A
Blue-gray coloration in the lips, tongue, mucous membranes and facial features
11
Q
What are you looking for when inspecting the hair
A
Texture and distribution
Infestation or infection
12
Q
What are you looking for when assessing the nails
A
Capillary refill
Color and texture
Shape
13
Q
What is clubbing of the nails and what is it associated with
A
The nail plate angle is 180 degrees or more
Associated with long-term hypoxic states, such as occur with chronic lung disease
14
Q
What is Hirsutism and what is a possible cause
A
Excess facial or trunk hair
Indicates a possible thyroid issue
15
Q
What are nits
A
Eggs of head lice and are usually located close to the hair shaft
16
Q
Which 3 cranial nerves are usually assessed together for eye movement
A
CN 3,4,6
17
Q
What 5 things do you look for when assessing the head and face
A
Skin and hair Size and shape Symmetry Facial movements Scalp
18
Q
When assessing the neck name 6 things to look for
A
Musculature Trachea Thyroid Symmetry Contour ROM - shrug CN XI
19
Q
What are Striae
A
Silver-to-pink stretch marks in pregnant women, women who have had children and anyone who has experienced significant weight fluctuations
20
Q
What are mees’ lines
A
Transverse white lines in the Nailbeds
Seen in clients who have experienced severe illnesses or nutritional deficiencies
21
Q
What is acromegaly
A
A large head in an adolescent or adult
Associated with excess growth hormone
22
Q
Hydrocephalus
A
An accumulation of excessive cerebrospinal fluid
Seen in infants and children, a head that is growing disproportionally
23
Q
What are some causes of enlarged or tender nodes
A
Infection, malignancy and other diseases
24
Q
What is enlargement with exophthalmos
A
Associated with a thyroid issues
Is an increase in the volume of the tissue behind the eye, the eyes will appear to bulge out of the face
25
Goiter
Bilateral thyroid enlargement
26
Name 8 things to look for when assessing the eye
```
External eye
Sclera and conjunctiva
Eye position
Visual acuity
Visual fields
Cranial nerve function
Pupils
Internal structures
```
27
Ectropion
An everted eyelid
28
Entropian
An inverted eyelid , can lead to corneal damage
29
Ptosis
Dropping of the lid
30
What is PERRLA
Pupils, equal, round, reactive to light and accommodation
31
Accommodate
When pupils constrict and the eyes converge (cross) as a person attempts to focus on an object moving toward them
32
Mydriasis
Enlarged pupils
May be seen with glaucoma
33
Miosis
Constricted pupils
34
Anisocoria
Unequal pupils
Maybe be seen in stroke, head trauma or could be normal
35
Myopia
Diminished distant vision
"Near sighted"
36
Presbyopia
Diminished near vision
"Far sighted"
37
Strabismus
Crossed eye
38
Amblyopia
Lazy eye
Is a result of constant strabismus of one eye
39
What is 100% visual efficiency
20/20
40
What does the numerator of the snellen acuity chart represent
What the patient can read/see at that distance
41
What does the denominator of the snellen acuity chart represent
What a normal eye can read at that distance
42
What does it mean to say someone has 20/40 vision
Patient can read at 20ft what a normal eye can read at 40ft
43
What does the corneal light reflex assess
Muscle balance of the eye
44
Which cranial nerve does the confrontation test assess
Peripheral vision - CN IV
45
What is a blown pupil
One that is widened out but also not reactive to light
46
What is the macula
The point of central vision
47
The ophthalmoscope is used to view what 4 things
Red reflex (should see red dots)
Optic disk
Retinal vessels
General background
48
What is the proper technique for examining a patients eye with an ophthalmoscope
Examine the patients eye on the same eye you are looking through
49
Name 4 things you are inspecting for when assessing the ear
Alignment
Lesions and trauma
Piercings
Tympanic membrane
50
What could bruising behind the ear mean
Head trauma
51
What is the tragus
The bottom part of the ear
52
Otitis externa
An outer ear infection
53
Otitis media
A middle ear infection
54
What does the weber test , test for
Lateralization of bone conduction
55
What is considered a positive result in a weber test
If vibration is louder in one ear
56
What does the rinne test , test for
Test compares bone conduction and air conduction
57
What is cerumen
Ear wax
58
What is considered a positive result for a rinne test
Air conduction greater (>) bone conduction
59
What should a normal tympanic membrane look like
Pearly, gray, shiny and translucent B
60
How does the tympanic membrane appear in otitis media
Red, inflamed, drainage, bulging tympanic membrane
Cone of light disturbed
61
Cone of light of normal tympanic membrane
Right ear - 5 o'clock
Left ear - 7 o'clock
62
To see in an adult ear you pull the ear
Up and back
63
To see in a child's ear you pull the ear
Down and back
64
Name 6 things to inspect while assessing the mouth
```
Lips
Tongue
Buccual mucosa
Hard and soft palate
Teeth
Pharyngeal wall
```
65
Patency
Is open, expanded or unobstructed
66
What are 4 factors that affect skin texture
Exposure
Age
Hyperthyroidism and other endocrine disorders
Impaired circulation
67
Pediculosis
Head lice infestation
68
Name 5 abnormal findings on the eyelids
```
Crust, scales Or swelling
Pterygium
Ectropion
Entropion
Ptosis
```
69
Pterygium
A growth or thickening of conjunctiva from the inner can this toward the iris
70
Stomatitis
Inflammation of the oral mucosa
71
Leukoplakia
Thick elevated white patches that do not scrape off , maybe precancerous lesions
72
Thrush
White curdy patches that scrape off and bleed
73
What are the ABCs of documentation
```
Accurate
Bias-free
Complete
Detailed
Easy to read
Factual
Grammatical
Harmless
```
74
Name 10 guidelines for documenting care
1. maintain confidentiality
2. correct form
3. chart clearly marked
4. write legibly
5. use black ink
6. dont leave blank lines
7. draw a line through incorrect charting and initial
8. sign all your paper chatting
9. no shorthand
10. only use approved abbreviations
75
Name 8 things included in a change-of-shift report
1. client demographics and diagnoses
2. relevant medical hx
3. significant assessment findings
4. treatments (ex:wound care)
5. upcoming diagnostics or procedures
6. restrictions (ex: diet,activity,isolation)
7. plan of care for the client
8. concerns
76
What are verbal orders
Spoken to you in person, not over the telephone
Should only be used during critical situations or emergencies
77
What are telephone orders
Received by phone and transcribed into chart order sheet
78
Name 6 things to remember when documenting telephone orders
1. write the order only if you heard it yourself
2. ensure the order makes sense sigh the clients status
3. repeat the order to confirm accuracy
4. spell unfamiliar names/pronounce digits of numbers separately
5. directly transcribe the order on the chart (date/time, text, TO with providers signature and your signature)
6. physicians must countersign within 24hrs
79
What is an occurrence report
An organizational record or incident report of an unusual occurrence, accident or error
80
List 8 examples of events requiring an occurrence report
1. fall
2. medication errors
3. family incidents/injuries
4. staff injury
5. unsafe environments
6. procedural errors
7. inadequate response to patient situation
8. lack of resources or supplies
81
Are occurrence reports apart of a patients health record
No !
82
Should you still complete an occurrence report even if there is no adverse impact on the client
Yes .. "Near misses" will lead to actual problems if left unreported
83
Name 5 things to include in an occurrence report
1. patients name,date,time,location
2. briefly discuss the incident in OBJECTIVE terms
3. quote if possible
4. identify any witnesses to the event, equipment involved and environmental conditions
5. avoid drawing conclusions or placing blame
84
What does SBAR stand for
Situation
Background
Assessment
Recommendation
85
Why is the SBAR form of documentation useful
Useful for interdisciplinary communication, especially critical situations requiring a clinicians immediate attention and action
86
List 4 situations that the SBAR style of documentation can be used
Change of shift
Patient transfers
Critical conversations
Telephone calls
87
SBAR related to the joint commission
The joint commission on accreditation of hospitals has added "standardized communication" to the patient safety goals and recommends SBAR as a best practice
88
What does the whisper test , test for
High pitched hearing loss
89
What is pulse deficit
The difference between the apical pulse and the peripheral pulse
90
What is orthopnea
Shortness of breath that occurs while laying flat
Seen a lot in ❤️ patients
91
Name 6 abnormal findings when palpating the posterior thorax and lungs
Nodules,lumps and tenderness on back
Chest not expanding symmetrically
Tenderness or curvature of spinous process
Asymmetry of vibrations with "99"
Crepitus
Subcutaneous emphysema
92
What is subcutaneous emphysema
Is when gas or air is in the layer under the skin
Looks like rice crispies under the skin
93
Name 4 abnormal findings while percussing the lungs
- tenderness with percussion
- hyperreasonance with percussion over lung fields
- dullness with percussion over lung fields
- tenderness with percussion of costovertebral angle
94
Characteristics of bronchial normal breath sounds
Pitch: high, loud
Duration: inspiration < expiration
Normal location: trachea and larynx; sounds harsh, hollow, tubular
95
Characteristics of bronchovesicular normal breath sounds
Pitch: moderate
Duration: inspiration = expiration
Normal location: over major bronchi where fewer alveoli are located
Posterior between scapulae, especially on right
Anterior around upper sternum in 1st and 2nd intercostal spaces
96
Characteristics of vesicular normal breath sounds
Pitch: low, soft
Duration: inspiration > expiration
Normal location: over peripheral lung fields where air flows through smaller bronchioles and alveoli
Sounds rustling like the sound of wind in the trees
97
Crackles
(Rales)
Popping open of alveoli or secretions
Occur with pneumonia and pulmonary edema
98
Wheezes
(Rhonchi)
Airway narrowing or obstruction
Occurs with asthma and emphysema
99
What are Cheyenne-stokes respirations
A cycle in which respirations gradually increase in rate and depth and then decrease
Caused by severe ❤️ failure, renal failure, meningitis, drug overdose and increased cranial pressure
100
What 2 groups of people are Cheyne-stokes respirations normal in
Infants and aging people
101
What is crepitus
Clicking or grating at a joint
"Creaking" of bones
102
What is stridor
Narrow or obstructed upper airway
103
When are wheezes usually heard
On expiration
104
When is stridor usually heard
Primarily during inspiration
105
What is grunting
Difficulty expelling air
106
What is pectus excavatum
"Funnel chest"
A condition in which the breastbone sinks into the chest ; sternum sticks out
107
What is Barrel chest
A condition in which the anteroposterior and lateral diameters may be equal 1:1 ratio
Instead of the normal 1:2 ration
108
What is the tail of spence
When breast tissue and lymph extend up into the axilla
109
What should you have a patient do if adventitious sounds are heard
Cough
110
Where can the aortic ❤️ sound be heard best
Second intercostal ; right sternal border
111
Where can the pulmonic ❤️ heart sound best be heard
Second intercostal ; left sternal border
112
Where can the tricuspid ❤️ sound best be heard
Fourth intercostal ; left sternal border
113
Where can the mitral ❤️ sound best be heard
5th intercostal ; midclavicular line
114
Name 3 abnormal ❤️ sounds
S3 , S4
Murmurs
Rubs
115
What is systole
The contraction , or emptying of the ventricles
116
What is diastole
Refers to the relaxation , or filling phase of ventricles
117
What is the proper order for stomach assessment
Inspect
Auscultate
Percuss
Palpate
118
Name 4 normal variations in abdominal contour
Flat
Rounded
Protuberant
Scaphoid
119
Normal bowel sounds
Occur every 5-15 seconds or 5-30 times per minute
120
Hyperactive bowel sounds
Loud , rushing sounds occurring every 2 or 3 seconds (more than 30 per minute)
May indicate diarrhea, early bowel obstruction or gastroenteritis (infection of the Gi tract)
121
Hypoactive bowel sounds
Very faint and infrequent (fewer than 5 sounds per min)
May occur after abdominal surgery or with bowel obstruction, infection or problems of innervation
122
What is ascites
An abnormal accumulation of fluid in the abdomen
123
Cranial Nerve I
Olfactory
Function: smell
Testing: smell
124
Cranial Nerve II
Optic
Function: sight
Testing: visual fields
125
Cranial Nerve III
Ocular motor
Function: extraocular movements
Testing: 6 Cardinal fields of gaze , pupillary reflex , pupillary reaction light and accommodation
126
Cranial Nerve IV
Trochlear nerve
Function: downward and inward movements of the eye
Testing: 6 Cardinal fields of gaze
127
Cranial Nerve V
Trigeminal
Function: sensory of face and jaw
Testing: sensory - cotton , motor - clench teeth
128
Cranial Nerve VI
Abducens
Function: lateral deviation of eye
Testing: 6 Cardinal fields of gaze
129
Cranial Nerve VII
Facial
Function: lacrimal gland, lid muscles and tongue (tasting)
Testing: puff cheeks, smile, show teeth, raise eyebrows, taste test
130
Cranial Nerve VIII
Acoustic
Function: hearing and balance, eardrum, ear canal
Testing: whisper test, weber, rinne, Romberg
131
Cranial Nerve IX
Glossopharyngeal
Function:
Testing: tongue , gag
132
Cranial Nerve X
Vagus
Function: palate, pharynx, larynx
Testing: gag , "ah" observe soft palate and uvula
133
Cranial Nerve XI
Spinal Accessory
Function: sternocleidomastoid and upper portion of trapezius
Testing: shrug shoulder, rom of neck
134
Cranial Nerve XII
Hypoglossal
Function:
Testing: protrude tongue, retract tongue, move tongue to right and left
135
List developmental modifications for infants and children
- have parents present and hold infants
- offer toddlers choices/praise for cooperation
- let the preschool child help with the exam; give reassurance
- support the school aged child's independence
- adolescents should provide privacy
136
Developmental modifications for older adults
- observe energy level; provide rest periods and limit position changes
- allow for extra time to interview and examine
- can't assume certain positions
- be alert for hearing and vision deficits
- assess the older adults functional status
- SPICES
137
What does SPICES stand for
```
Sleep disorders
Problems eating or feeding
Incontinence
Confusion
Evidence of falls
Skin breakdown
```
138
What is hypotonia
"Floppy baby syndrome"
Poor muscle tone is a condition usually detected at birth or during infancy
139
ROM of the neck
```
Flexes
Extends
Hyperextend
Bend laterally
Rotate side to side
```
140
ROM of shoulder
```
Flexion
Extension
Hyperextended
Abduct
Adduct
Rotate internal and external
```
141
ROM of the elbow
Flexion
| Extension
142
ROM of wrist
```
Supination
Pronation
Radial deviation
Ulnar deviation
Flexion
Extension
Hyperextend
```
143
ROM of fingers
```
Spread the fingers (abduct)
Bring them together (adduct)
Make a fist (flex)
Extend the hand (extend)
Bend fingers back (hyperextend)
Bring thumb to index finger (palmar adduction)
```
144
ROM of hip
```
Flexion
Extension
Hyperextend
Abduction
Adduction
External/internal rotation
```
145
ROM of knee
Flex
| Extend
146
ROM of ankle/foot
```
Dorsiflex
Plantar flex
Evert
Invert
Abduct
Adduct
Rotate
```
147
What is ABduction
Moving AWAY
148
What is ADDuction
Moving toward
149
ROM of spine
```
Bend at the waist
Stand upright
Hyperextend (bend backward)
Bend laterally
Rotate side to side
```
150
Soft palate movement is associated with which cranial nerves
Cranial nerves IX and X
Saying ah , gag reflex
151
Tongue movement is associated with which cranial nerves
Cranial nerves IX and XII
152
The integumentary system consists of what 4 parts
Skin
Mucous membrane
Hair
Nails
