Final Exam Concepts Flashcards
Inspection
Assessment technique done initially in Physical Assessment
Palpation
Assessment technique that should be used to elicit crepitus in a patient who sustained chest injury
Auscultation
Assessment technique that should be used when listening to the heart sound
Percussion
*Use the non-dominant middle finger on the area of the body to be percussed and use the tip of the middle finger as tapper
*Assessment technique that should be used to elicit diaphragmatic excursion.
Indirect Percussion
Assessment technique that should be used to assess lung tissues or lobes of the lungs or client with full or distended bladder.
Direct Percussion
Assessment technique that should be used to assess sinus infection
Goniometer
Instrument used to assess the degree of joint flexion and extension
Doppler
Used to assess non palpable pulses
Wood Lamp
Used to assess presence of fungal infection of the skin
Skinfold Caliper
Used to assess subcutaneous thickness
Transilluminator
Used to detect blood, fluid, or masses in the body cavities
How do you grade pulses (0-4+)
0-no pulse
1+ weak and thready
2+ normal
3+ brisk
4+ bounding
What is the difference between a target and angular lesion?
Target lesions have a concentric circles of color. Erythema and Anular has just one circle lesion, like ringworm
What is the difference between discreet lesions and confluent lesions
Discreet lesions are separate and confluent lesions run together
What is the difference between linear lesions and grouped lesions
Linear lesions form a line and grouped lesions have several lesions that appear in clusters/ lesions that are together
Describe a wheal lesion
A lesion that is caused by insect bites or hives that are reddened with an irregular border
Describe Lichenification
Lesions that are rough, thickened, hardened epidermis due to constant scratching and rubbing.
Describe Vesicles
Palpable round or oval lesions with a translucent wall filled with fluids
Describe Atrophy
Translucent, dry, paper-like wrinkled skin due to loss of collagen & elastin. Common in the elderly.
What are the normal findings in adults regarding the lymph nodes and what assess technique is used?
*Adults- non-palpable
*Assessment technique-gentle, circular motions using 2-3 finger pads.
CNs #1
Olfactory-sense of smell of both nostrils
CNs #2
Optic- Snellen Test (distance) & Rosenbaum (Close)
CNs #3
Oculomotor
CNs #4
Trochlear- PERRLA & 6 Cardinal Field of Gaze
CNs #6
Abducens
CN #5
Trigeminal-Clenching of teeth, Move jaw Right to left, open and close mouth, protrude and retract jaw
CNs#7
Facial-movement of face, puff cheeks, smile, frown, raise eyebrows up & down
CNs #8
Vestibulocochlear- whisper test and Romberg’s test
CNs #9
Glossopharyngeal- swallowing and gag reflex
CNs #10
Vagus- Swallowing and phonation
CNs #11
Accessory- shoulders up and down with- without resistance
CNs #12
Hypoglossal- movement of tongue, up and down, right to left
What is a venous lake
Soft lesion on the lips or neck that is elevated, dark blue and compressible. Common seen in the elderly.
What is a port wine stain?
*Flat, irregularly shaped, pale red to deep purple red.
* Color deepens in response to exertion, crying, emotional response or exposure to extreme temperature.
* Present at birth and typically does not fade.
What is hemangioma
A bright red raised lesion, does not blanch with pressure, present at birth or few months after birth, typically disappear at age 10.
What is spider angioma
A flat bright red dot with tiny radiating blood vessels ranging from pinpoint to 2 cm, will blanche with pressure.
Differentiate the 3 types of abdominal palpation
- Light palpation-use finger pads of one hand-1/2 to 1 cm use for patient with abdominal pain, assess skin texture, & inflamed area
- Moderate palpation finger pads 2-3 cm- use to determine the depth, size, shape, consistency and mobility of organs as well as pain, tenderness or pulsation
*Deep Palpation- use palmar surface of the hands bimanually - 4- 5 cm- caution must be used. It is used to assess organs that lie deep within the body such as liver, spleen or kidneys
When a client suddenly refused your examination. What should you do as a nurse?
Document what was done and what was refused
What question should you ask a client when you suspect Lyme DIsease?
Have you been hiking recently?
What is the indication of an open sore in the has that has not healed for several months?
The indication is the client may have malignancy or skin cancer.
A client with nystagmus will demonstrate?
Jerky eye movements during the 6 cardinal field of gaze
Normal Consensual response?
Illuminated eye, pupil will constrict faster than the other eye but the other eye pupil will constrict sluggishly
Describe the Weber Test
*Normal findings- equal lateralization of vibration to the right and left ear
*Patient with impacted cerumen of the right ear- sounds lateralization will go to the right ear with cerumen
Normal Rinne test findings
Air conduction is 2X greater than bone conduction
When sinuses are filled with fluid…?
They will not transilluminate, red glow is absent.
What is craniosynostosis?
A condition when infants have elongated head and face and orbits of eyes are altered
What is hydrocephalus
A condition when infants have enlarged head with visible scalp veins due to accumulation of on non-draining (cerebrospinal fluid).
What is presbyopia?
Older adult clients (>45 Y/O), report difficulty with near vision
What is hyperopia?
Young adults with difficulty with near vision
What is myopia
Difficulty with far vision
When a nurse is triaging patients in Ophthalmology clinic the patient that requires immediate attention will be the client with…
… acute Glaucoma because increase pressure in the eyes that can lead to blindness
Describe Otitis Externa
An infection of the outer part of the ear but tympanic membrane is still normal pearly gray
Describe Otitis media
An infection of external part of the ears and ossicles
Describe Otitis Interna or Labyrinthitis
An infection goes into the inner ear affecting the semicircular canal, cochlea, and vestibule
S/S-severe vertigo and dizziness
Describe a normal tympanic membrane
Shiny pearly grey
It is appropriate for the nurse to use an otoscope in the physical assessment…
When funneling light into the ear canal
The manifestation of patient with retinal detachment will be…
Diminished vision of the affected eye
The technique that a nurse will use to assess the eom (extra ocular muscle movements) will be…
Assessment 6-cardinal field of gaze using the wheel wagon method or the H method
Describe diabetic retinopathy
The leading cause if blindness in the USA
Enlarged lymph nodes may indicate what?
Infection, normal findings are non-palpable lymph nodes for adults. Children may or may not have enlarged lymph nodes & this can still be normal, however, refer to MD if palpable
When testing the integrity of CN III, the nurse must advise the patient…
to look up and down without moving the head
White patches on the tympanic membrane indicate what?
Scarring from a previous infection
When testing for Romberg test…
The nurse must advise the client to stand erect with feet together, hands on the sides and close eyes for 20-seconds
What are the normal findings the Romberg Test and what should be done for a patient with abnormal findings?
*Normal findings -no swaying
*Swaying more than 2 inches is abnormal
*For abnormal Romberg test to meet the elimination needs of the client provide a bedside commode
How do you interpret a Snellen test of a patient with 20/50 reading?
This patient sees at 50 feet what a person with normal vision sees at 20 feet.
Describe a sinus headache
headache from a sinus infection
Describe a classic migraine
headache preceded by aura, seeing spots, flashes of light, feeling nauseated, or experience numbness and tingling of the face and extremities
Describe a cluster headache
numerous headaches occur over a period of days or months. No aura, onset is sudden and may last for a few minutes or a few hours
Describe a tension headache
Also known as muscle contraction headache. Onset is gradual, pain is steady. Usually associated with stress and being overworked. May be unilateral or bilateral, ranges from cervical region to the top of the head.
Differentiate Entropion and Ectropion:
*Entropion- upper lid inverted into the eyes causing the eyes to be irritated.
*Ectropion- lower lid is everted downward exposing the conjunctiva.
What is the most common type of Hyperthyroidism?
Graves’ Disease
What are the cues or signs and symptoms of Gingivitis?
(1) Red gums
(2) Bleeding gums
(3) Receding gums
Expected findings for client with Bell’s Palsy?
(1) Muscle distortion
(2) Pain behind the ear
(3) Impaired Taste
If sinuses are not filled with fluid, you will…
…elicit red glow on transillumination of the sinuses using your penlight. If sinuses are filled with fluid, it will not transilluminate, you will not elicit red glow or red glow is absent.
For elderly client when is the best time of the month to perform SBE?
- Preferably the same day every month.
- For a client that is still menstruating, 3- 5 days after the menstrual period when the hormones are more stable.
Describe Intraductal Papilloma
The most common cause benign nipple discharge of post-menopausal client complaining of leakage of serum or bloody discharge of the breasts.
Describe Benign Breast or Fibrocystic Breast
*common in the 20’s
*S/S: tenderness, nipple discharge, & thickening of the breast tissues
Describe fibroadenoma
*A defined breast tumor like with no tenderness or discharge.
* Common in adolescent girls 15 to 35 years old.
A client with an orange-peel or Peau D’Orange skin appearance on the breast is an indication of?
Malignancy
Any change in consistency of a breast lump must be?
Evaluated by the physician
Describe an early sign of hypoxia
Altered level of consciousness
Use whispered pectoriloquy or bronchophony on auscultations when…
Assessing a client with bilateral pneumonia and both lungs are filled with fluid, the sounds you will hear are sounds that are loud and clear bilaterally.
What are the normal lung sounds with no fluids during whispered pectoriloquy and bronchophony
You will hear sounds that are soft & almost indistinguishable for Whispered Pectoriloquy & Muffled sounds for Bronchophony.
The most appropriate technique in assessing the respiratory system is?
Assessing from side to side
Describe tracheal breath sounds on auscultation
over the trachea- Inspiration is < than expiration (harsh, high pitched)
Describe bronchial breath sounds on auscultation
superior to each clavicle & in the 1st ICS, E>I (loud high pitched)
Describe bronchovesicular breath sounds on auscultation
over major Bronchi in the 2nd and 3rd ICS between Scapula I=E (medium loudness, medium pitched)
Describe vesicular breath sounds on auscultation
remainder of the lungs I>E (soft, low pitched)
Describe bradypnea
slow regular rate <10 per minute (DM Coma, Drug Induced, > intracranial pressure)
Describe hypoventilation
irregular, shallow rate <10 (narcotic OD, anesthetic, prolonged bedrest, chest splinting)
Describe hyperventilation
rapid deep rate>24/minute (extreme exertion, fear, DM ketoacidosis, hypoxia, salicylate OD hypoglycemia)
Describe tachypnea
rapid, shallow rate >24 (fever, fear, exercise, respiratory insufficiency, pleuritic pain, alkalosis, pneumonia)
Describe Cheyne-Stokes
regular pattern with period of deep breathing alternating with apnea (Normal children and aging, heart failure, uremia brain damage, drug induced respiratory depression, common in elderly dying patient)
Describe Biot’s/ Ataxic
Irregular pattern respiration- Shallow deep respiration with periods of apnea (respiratory depression and brain damage)
Describe normal breathing
(1) Eupnea even, regular I=E
(2) Eupnea w/ occasional sigh
Describe coarse rales/ crackles
low pitched, bubbling, loud & moist (collapsed or fluid filled alveoli). Example: Lobar Pneumonia
Describe Ronchi Sibilant
high pitched continuous (blocked airflow as in Asthma, infection)
Describe Ronchi Sonorous
low pitched continuous, snoring & rattling (Fluid Blocked airway) Example: COPD
Describe Stridor
loud, high pitched, crowing heard w/o stethoscope (obstructive upper airway)
Describe Friction Rub
low pitched grating rubbing Example: Pleural inflammation
What is Elliptical Chest Configuration
Normal chest configuration wherein the lateral diameter of the chest is 2:1 with the anteroposterior diameter
*By age 6, with normal child development & growth the child will have elliptical chest configuration.
Infant chest configuration is…
barrel chest which is rounded with equal lateral and anteroposterior diameter
Barrel chest is common in what patients?
COPD and elderly
Describe Pectus Carinatum or pigeon chest
Forward displacement of the sternum with depression of the adjacent cartilage. No treatment is required.
Describe Pectus Excavatum or Funnel Chest
*Depression of the sternum and adjacent cartilage
*Murmur maybe present with cardiac compression
*Surgical intervention maybe required in severe cases
Describe Scoliosis
*Common in females- lateral curvature of the spinous process (thoracic & lumbar curvature or rotation)
May result in elevation of the shoulder and pelvis Deviation greater than 45
*May cause distortion of the lungs resulting in lung volume
Describe kyphosis
Exaggerated posterior curvature of the thoracic spina, associated with aging It may, lung expansion and > cardiac problem
Describe lordosis
Exaggerated curvature of the lumbar vertebrae during pregnancy
Air trapped in the lungs is the indication of…?
Hyperresonance sound on percussion of client lung area
In assessing a patient with pleural effusion on auscultation…
The breath sounds that you will expect will be absent breath sounds on the affected lung or lobes of the lungs.
Fluid filled alveoli adventitious sounds that are…
low-pitched, loud, moist, and bubbling quality on auscultation
Describe a fluid blocked airway
Adventitious sounds on auscultations when the lung sounds are low pitched, continuous & rattling quality
Describe precordium
Part of the chest where you perform cardiac assessment
Landmark of the Aortic area?
2nd ICS right sternal border
Landmark of the Pulmonic area?
2nd ICS left sternal border
Landmark of the ERB’S Point?
3rd ICS left sternal border
Landmark of the Tricuspid area?
4th ICS left sternal border
Landmark for Mitral or PMI in adult?
5th ICS, left mid-clavicular line. Location of PMI in Children- 4th ICS, LMCL
Landmark of the angle of Louis?
Articulation of the manubrium and the body of the sternum
Pathologic cardiac murmurs are associated with the following:
(1)Tricuspid stenosis
(2) Mitral regurgitations
(3) Aortic regurgitation
Differentiate b/w Arterial insufficiency and Venous insufficiency:
- Arterial Insufficiency- affected leg is cold and no more growing hair.
- Venous Insufficiency- affected leg skin temperature is still normal- warm.
- Both anomalies the patient experiences pain and other symptoms
Describe ECG
Electrical representation of the cardiac cycles documented by deflections on recording paper
Describe depolarization or contraction
Happens after stimulation by the electrical current wherein the cardiac cells are positively charged
Describe repolarization
Happens after contraction wherein the inside of the cardiac cell returns to negatively charged. P Wave- represents part of Atrial depolarization. PR Interval- time needed for electrical current to travel across both atria & arrive at AV node. Atrial Repolarization is hidden behind the QRS.
P wave
Is known as atrial depolarization
Atrial Repolarization
Is hidden behind the QRS
QRS Complex
Is known as ventricular depolarization
T wave
ventricular repolarization
QT interval
Represents the beginning of ventricular depolarization to the moment of repolarization which represents ventricular contraction
Describe Allen’s test
The test is performed to determine the patency of the radial or ulnar arteries
Describe Raynaud’s Disease
The findings that a Nurse will anticipate will be spasm and tingling sensation of hands and fingertips. Hands turn whitish, cyanotic and then reddish or presence of rubor. Common in young healthy female secondary to connective tissue disease, drug intoxication, pulmonary HTN or trauma
Describe DVT
*occlusion of deep veins such as the femoral or pelvic circulation by blood clot
*Subjective findings: sudden intense sharp pain along iliac, popliteal or calf muscles. Increase pain w/ dorsiflexion of the foot. *Objective symptoms- unilateral edema, low grade fever & tachycardia
*DVT- can migrate to the lungs resulting in PE (Pulmonary Embolism)
Thin red lines or splinter hemorrhages in the nail beds are present in client with
Infective Endocarditis
A pathologic cardiac murmur during cardiac assessment is
- Related to structural abnormalities of the heart
*Examples: Mitral regurgitation, Tricuspid Stenosis, Aortic regurgitation
How should a nurse explain to the patient the S2 heart sound or (dub)
Closure of the semilunar valve. Heard loudest at the base of the heart. S1(lub) closure of the Tricuspid and Mitral valves. Heard loudest at the apex of the heart
Describe the SA Node
*known as the pacemaker of the heart where the initial electrical pulses occur
*It fires 60-100 joules/minute. AV node fires 60 joules/minute and Bundle branches fire 40-60 joules/minute
S4 Atrial Gallop is….
heard before S1 & S3 ventricular gallop is heard after S2
5 major risk factors of heart disease are:
1) Smoking
(2) HTN
(3) Obesity
(4) DM
(5) high Cholesterol
Patent Foramen Ovale
- Is a passageway for blood between the right and left atria
- Should close shortly after birth
Describe Patent Ductus Arteriosus
The opening between the pulmonary artery & descending aorta, closes 24-48 hours after birth
Describe Tetralogy of Fallot
A cardiac condition where there are 4 cardiac defects in a baby that is life-threatening, surgery must be performed immediately
Describe the 2 cardiac nerves of the heart
(1) Sympathetic-stimulates the heart, increase HR & Increase dilatation of the coronary arteries (2) Parasympathetic- decrease stimulation of the HR, decrease HR & decrease dilatation of the coronary arteries
What are the manifestations of heart failure?
(1) fatigue
(2) dyspnea
(3) tachycardia
(4) weak peripheral pulses
(5) ankle edema
Describe the grading of pulses
0 no pulse
1+ weak & thready
2+ normal
3+ Brisk
4+ Bounding
For patients with new arteriovenous graft (AV) graft, which technique should the nurse perform to assess the potency of the graft?
Palpate the site for a thrill
Dorsalis Pedis location
top of the feet, lateral to the big toe
Popliteal Pulses location
Behind the knees medially
Femoral Pulse location
Inguinal areas
Posterior Tibialis location
At the grooves behind the medial malleolus and Achilles tendon
Radial Pulse location
Lateral wrist, in line with the thumb
Ulnar pulses location
Medial wrist, in line with the small fingers
What are the two types of abdominal mappings or reference points?
- 4 Quadrants
- 9 Region
When the intake of the client is more than the output?
The client is retaining fluid
What is the landmark for assessing CVAT?
Costovertebral Angle using Blunt Percussion
What does it mean when the output is more than the intake?
- The client is secreting more fluid
*Observed in patients with: DM, Kidney Failure, or access intake of fluids
What are the sounds heard when percussing the lower border of the liver at the Right Upper Quadrant at the midclavicular line?
Dullness
Describe a + Blumberg Sign
A sharp stabbing pain as the compressed abdomen returns to non-compressed state indication of positive to appendicitis, peritonitis or peritoneal irritation “emergency.”
Describe a + Rovsing Sign
A sharp pain on the right lower quadrant of the abdomen when the nurse palpates the left lower quadrant- sign of acute appendicitis or peritoneal irritation.
Describe a + Psoas Sign
Right lower quadrant pain when right leg is raised up with resistance- + positive to appendicitis
Describe a + Murphy’s Sign
Upper right quadrant pain when client is asked to deep breath, while nurse is palpating the lower border of the liver - positive to Cholecystitis
Describe a + Cullen’s Sign
Ecchymosis or bluish discoloration of the abdomen-indication of
possible Ruptured ectopic pregnancy or bleeding in the abdomen
Describe the meaning of pain at McBurney’s Point
+ to Acute Appendicitis. Location Of McBurney’s point middle third of the imaginary line from the umbilicus to the right inguinal area
Normally, all 4 quadrants of the abdomen will have…?
Tympanic Sound
*Except for the lower border of the liver on the upper right quadrant wherein the sound is dullness because the liver is a solid organ
Types of Abdominal Palpations
(1) Light- ½ to 1 cm depth, one hand use to assess tender abdomen
(2) Moderate- 2-3 cm depth one hand
(3) Deep- 4-5 cm depth, bimanual – MD & NPC
Flat Contour of the Abdomen
Normal for a skinny person
Scaphoid or concave abdomen
normal for a very skinny person
Rounded contour of the abdomen
Normal for obese, toddler, or early pregnant
Protuberant contour of the abdomen
Normal for some toddler, late stage of pregnancy, and abnormal in case of client with ascites
During inspection which of the abdominal findings should the nurse report immediately
Strong abdominal pulsation to r/o AAA
the main organs that a nurse will assess at the left upper quadrant of the abdomen
stomach and spleen
the main organs that a Nurse will assess at the right upper quadrant
liver and gallbladder
When client has diverticulitis which quadrant of the abdomen will the Nurse assess?
Left lower quadrant
What is the correct sequence for assessing the abdomen?
(1) Inspection
(2) Auscultation
(3) Percussion
(4) Palpation
Describe Hepatitis
Hepatitis is the inflammation of the liver caused by viruses, bacteria, chemicals or drugs or parasite
What are the types of Hepatitis and how are they transmitted
Types are:
*Hepatitis B (HBV)- transmitted by blood, sexually, perinatally & parenterally.
*Hepatitis C (HCV)- transmitted by blood & blood products & parenterally- more common in clients with tattoos.
*Hepatitis D - the same as (HBV)
*Hepatitis A- (HAV)- transmitted by fecal or oral route- more common in children.
*Hepatitis E (HEV)- transmitted by drinking dirty water supply. Common for travelers in underdeveloped countries.
Anuria
Below 100 cc urine output in 24 hours
Oliguria
Between 100 cc to 400 cc urine output in 24 hours
Polyuria
Frequent Urination
Hematuria
Blood in the urine
Dysuria
Difficulty of urination
Nocturia
Frequent urination at night
Glycosuria
Sugar in the urine
Enuresis
Involuntary urination at night, common in 5 years old or younger (has familial tendency)
Normal bowel sounds on auscultation are…
5-30 times per minute in each quadrant which are irregular, high pitched & gurgling
Borborygmi
*Frequent loud gurgling bowel sounds when a person has not eaten for 5-7 hours.
*Normally when there are no other S/S
*Can be abnormal when accompanied by other GI S/S
Hyperactive Bowel Sounds
Due to diarrhea or gastritis
Hypoactive bowel sounds
Due to post op patient or bowel obstruction
Absent bowel sounds
Due to paralytic ileum
Friction Rub Bowel Sounds
Grating rubbing together or inflamed organs
Describe Colitis
*Inflammation of the colon
*S/S: Abd pain, diarrhea & Bloody stool
*May require medical interventions
Describe Crohn Disease
*chronic inflammation of the GI, can involve any part of the lower intestine
*S/S: diarrhea, abdominal pain & Wt. loss
*No medical interventions required
Risk for PUD
(1) Smoking
(2) NSAID
(3) Helicobacter Pylori
Describe Glomeruli
Clusters of capillaries of the kidneys that filter 1 liter of fluid per minute to get rid of toxins, waste & foreign matter from the blood
Describe Uremia
*Hallmark of Chronic Renal Failure * Urine products built up in the blood
*S/S: N/V, anorexia, altered mentation, uremic frost on the skin. edema, fatigue & weight loss
Exposure to extreme environmental temperature will subject a person to…?
Hypernatremia (too much sodium in the blood)
Manifestations of a client with Hypernatremia include:
(1) Hypotension
(2) weakness
(3) Tachycardia
(4) dry mucus membrane
(5) oliguria
What are the part of the Diencephalon?
Thalamus
Hypothalamus
Epithalamus
What are the 2 parts of the Nervous System?
Central & Peripheral
Which clinical manifestation does the nurse anticipate when assessing tremors associated with Parkinson’s Disease?
Rhythmic Shaking
What concept should a nurse use to explain why decreased in height occurs with aging?
Shortening of the vertebral column
What is the main difference between Osteoarthritis & Rheumatoid Arthritis?
Osteoarthritis pain is aggravated by activities whereas Rheumatoid Arthritis pain is improved while doing activities
What symptom should a nurse detect for the risk of developing osteomyelitis with a patient with an open metacarpal fracture?
Fever
When assessing the range of motion of the finger or feet, when nurse ask the client to move the finger or foot outward away from the center of the body it is known as…
Abduction
Moving toward the center of the body is…?
Adduction
What are the risk factors for Osteoporosis?
Sedentary Lifestyle or no exercise
The findings of clients with Positive Carpal Tunnel Syndrome when conducting Phalen’s test are…
Tingling sensation and numbness over median nerve, palmar surface of the thumb, the index finger, middle finger, and part of the ring finger with pain in the upper arms, shoulders, neck & chest when client is asked to hold the wrist at 90* flexion for 60 seconds or 1 minute
Describe Tinel Test
Direct percussion on median nerve- Normal, no pain or tingling sensation on the arm surrounding the median nerve
When assessing a client with shoulder pain, what findings will indicate rotator cuff injury?
Inability to abduct the arm at the shoulder
What reflex is elicited when tapping directly with the flat end of the DTR hammer 2-3 inches above the wrist with palm in semi- prone position?
Brachioradialis Reflex
What reflex is elicited when tapping indirectly with the pointed end of the DTR hammer at the antecubital area of the arm, with palm in semi- prone position?
Bicep Reflex
Describe Plantar Reflex
Trace the sole of the foot with a tongue depressor upward to toes in an inverted “J”- Normal findings- downward response of hallux & toes
What findings will the nurse document when a patient is having difficulty of ambulation due to unsteady gait with wide base, slapping & swaying which is common in Multiple Sclerosis, Drug/Alcohol Intoxication?
Ataxia
What is the nurse assessing when drawing a letter with the use of Q-Tips on the client’s hands with eyes closed and client is ask to identify the letter?
Graphesthesia. Inability to identify may indicate Cortical Disease (CBD- Corticobasal Degenerative Disease- involves the pathology of the cerebral cortex & basal ganglia. S/S: Marked disorder in movements: cognition is classified as one of the Parkinson’s Plus Syndrome that occurs at age 5-=70. Duration of the Disease is 6 years) Definitive DX is through Neuropathology Exam
What is the nurse assessing when a client with closed eyes is asked to identify a familiar object placed on her hand?
Stereognosis- Inability to identify may indicate Cortical Disease
What is the test that a nurse should perform when assessing for sensory functions?
Touch the patient with eyes closed with soft, sharp or dull object & client is asked she can feel & identify the sensation.
What would the nurse expect normally when assessing for the normal Achilles Tendon Reflex?
Plantar Flexion of the foot & heel jump
When caring for a client with T-4 spinal injury what is the indication that the client is at risk for experiencing autonomic dysreflexia?
The client’s bladder becomes distended.
Describe the Babinski Sign reflex
dorsiflexion of the big toe & fanning of the rest toes, is normal in children up to 2 years old
Babinski Sign is abnormal after 2 years old which will indicate…
CNS pathology- upper neuron disease
Describe Plantar Reflex (Adult(
With the use of tongue depressor trace from heel of foot toward the toes to the big toe in an inverted “J”. Normal response: downward response of hallux or big toe & toes
Describe Romberg’s Test
Test for balance, feet together, hands to the sides, closed eyes for 20 seconds, while nurse is supporting client front & back. Provide “Bedside Commode” to meet the elimination needs of client.
Describe Crepitation
Pain, stiffness, crunching, and grating sounds of joints
Describe objective findings when assessing a client with Meningitis.
(1) Fever
(2) Irritability
(3) Vomiting
(4) Seizures
(5) Coma
