Funda - Enhancement Notes

Question 1

Apical pulse location

Answer 1

5th left intercostal space; mid clavicular

three inches to the left of the sternum at the fourth, fifth or sixth intercostal spaces

Question 2

what is Pulse deficit

Answer 2

difference between apical and radial

Question 3

BP Deflating Cuff

Answer 3

deflate cuff 30-45 seconds
2-3mmHg per second

Question 4

Correct sequence of Korotkoff sounds phases

Answer 4

I - A sharp tapping
II - A swishing sound
III - A thumping sound (diastolic)
IV- Then a softer bowling muffled sound
V - Then silence

Question 5

Placing stethoscope in assessing BP

Answer 5

Place cuff 1 inch/2.5cm above the antecubital space
ear attachments tilt slightly forward

Question 6

Responsibilities when 88 is systolic (below normal) *normal is 90 above.

Answer 6

Recheck the blood pressure manually after ambulating the client safely

Question 7

Inspecting skin surfaces and report pigmented skin lesions that:

Answer 7

have irregular borders

Question 8

Assessing skin surfaces

Answer 8

*A- Asymmetry
*B- Border regulation
*C- Color Variation
*D- Diameter less than 6 (normal)

Question 9

Browned skin patient has pallor. What is the specific observation for this pt?

Answer 9

shiny skin; edematous

Question 10

what part is responsible for balance

Answer 10

Cerebellum & Vestibulocochlear nerve (ears)

Question 11

process of Romberg test - balance

Answer 11

standing feet together and eyes closed for a short time

Question 12

Assessing superficial lymph nodes

Answer 12

Gently palpate using the pads of the index and middle fingers

Question 13

Thyroid Location

Answer 13

Midline, with parathyroid glands easily palpated bilaterally

Question 14

Sites to auscultate heart

Answer 14

aortic, pulmonic, tricuspid, apical/mitral

Question 15

Assessing Jugular venous distention

Answer 15

Supine with head of bed elevated 30 degrees

Question 16

Thoracic Assessment
Normal

Answer 16

Transverse must be greater than anteroposterior diameter

Question 17

Thoracic Assessment
Barrel Chest

Answer 17

T=AP (1:1)

not normal for adults ; normal for newborns.
- The chest looks puffed out, like a barrel, commonly seen in chronic obstructive pulmonary disease (COPD).

Question 18

Thoracic Assessment
Pigeon Chest (Pectus carinatum)

Answer 18

AP>T
The chest looks pointed or triangular when viewed from the front.

Question 19

Thoracic Assessment
Funnel Chest (Pectus excavatum)

Answer 19

AP<T
The chest looks indented or caved in when viewed from the front.

Question 20

Percussion sounds
Normal sound

Answer 20

drum like sound; Tympany/abdomen

Question 21

Percussion sounds
Thud-like sounds

Answer 21

produced by a dense tissue: Spleen/liver

Question 22

Percussion sounds
Flat sound- dull sound

Answer 22

bone & muscles

Question 23

Percussion sounds
Hyperresonance

Answer 23

more booming and hollow; emphysema; pneumothorax; asthma

Question 24

Assessing vocal fremitus

Answer 24

Ask client to repeat words like 99 while palpating both the posterior and anterior chest

Question 25

Inspecting the Breast Tissue - Position?

Answer 25

sitting position

Question 26

How to observe for retractions

Answer 26

- Raise arms above the head - Push the hands together, with elbows flexed - Pressed the hands down on the hips

Question 27

How to spread breast tissue evenly over the chest wall during an examination in supine position

Answer 27

the ipsilateral arm overhead with a small pillow under the shoulder Breast exam is for changes not for palpating tumors

Question 28

Most common side for breast lumps

Answer 28

near armpits

Question 29

Techniques for self-breast exam

Answer 29

- Vertical - Circular - Wedge

Question 30

Information for the patient about mammography

Answer 30

- result would be within 24-48 hours - in supine or sitting position - hold breath when film is taken - xray will be used

Question 31

Nursing Considerations about mammography

Answer 31

Avoid using deodorants and talcum powder

Question 32

Abdominal assessment position

Answer 32

supine with legs slightly flexed

Question 33

Palpating the abdomen

Answer 33

- Palpate the sensitive areas of the abdomen last - Depress the abdominal wall 4-6cm

Question 34

Steps in Normal Physical Exam

Answer 34

- IPPA - Inspection, Palpation, Percussion, Auscultation

Question 35

Steps in Abdominal Exam

Answer 35

- IAPP - Inspection, Auscultation, Percussion, Palpation

Question 36

12 Cranial Nerves

Answer 36

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Question 37

Homan's sign is a sign for? -lifting legs

Answer 37

DVT

Question 38

Inspecting Inguinal Areas for Bulges

Answer 38

Hold breath and strain for intra-abdominal pressure

Question 39

Performing self-testicular examination. Inform the client:

Answer 39

- perform test monthly after warm shower - contact HCP if there's a painless pea-sized nodule. Wala dapat nodule

Question 40

Cremasteric reflex test using?

Answer 40

using cotton applicator

Question 41

Corneal reflex test using?

Answer 41

using wisp of cotton

Question 42

When a patient is wandering the hospital to look for a bathroom. Best intervention is

Answer 42

provide scheduled toileting during the night shift

Question 43

To prevent falls ?

Answer 43

lower the bed