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Funds Test 2 > Head to Toe Assessment > Flashcards

Head to Toe Assessment Flashcards

1
Q

Metformin

A

Biguanide

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2
Q

Glipizide

A

Sulfonylureas

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3
Q

Prandin or Starlix

A

Glinides

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4
Q

Avandia

A

Thiazolidinediones

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5
Q

Metformin onset

A

less than 1 hour

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6
Q

Glipizide onset

A

15-30 min

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7
Q

When obtaining data…

A

General to specific
Assess all areas and determine problem areas
Ask more focused questions about problem areas

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8
Q

Pre-orientation phase

A

Before you meet the patient

Gather information on them

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9
Q

Orientation phase

A

Explain purpose of interview

  • Establish nurse-patient interview
  • Inspect apperance and behavior
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10
Q

Working phase

A

Collect data regarding chief complaint

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11
Q

Termination phase

A

Clue that the interview is coming to an end

summarize, give opportunity to ask questions

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12
Q

Subjective data

A

What patient/family tells you

“Statement”

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13
Q

Objective data

A

Findings with physical assessment
Diagnostic test results
“Observed”

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14
Q

Detailed description of problem using open ended questions

A
  • Onset, progression, duration
  • What may have caused the problem
  • What makes it better or worse?
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15
Q

Mental Health Assessment

A

Appearance
Behavior
Cognition
Thought process

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16
Q

Order of Physical Assessment

A
  1. Inspect
  2. Palpate
  3. Percussion
  4. Auscultate
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17
Q

Transgential Lighting

A

Directing light from pen light or lamp to the areas being inspected

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18
Q

Used to assess pulse

A

Pads of fingers

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19
Q

Used to assess temperature

A

Dorsal of hand

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20
Q

Used to assess vibration

A

Palm of hand

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21
Q

Light palpation

A

1cm in depth

22
Q

Deep palpation

A

4cm in depth

23
Q

Diaphragm of stethescope

A

Used to hear bowel and breath sounds

24
Q

Bell of stethescope

A

Low pitched

Extra heart and vascular sounds

25
Q

Before auscultating on a hairy chest..

A

Moisten the hair, the hair can cause abnormal sounds (crackles)

26
Q

How would you check pallor or jaundice on someone with dark skin?

A

Sclera or inside mouth (gums)

27
Q

PERRLA

A

Pupils equal, round, responsive to light, and accomodate

28
Q

JVD

A

Jugular Vein Distention

May signal fluid volume excess

29
Q

Clubbing

A

Due to lack of oxygen to capillary nail beds

Can be due to smoking

30
Q

Turgor

A

Assesses skins elasticity

Tenting can be a result of dehydration

31
Q

Eupnea

A

Normal quiet respiration

32
Q

Which lung is shorter?

A

Right lung, to accommodate room for liver

33
Q

Which lung is narrower?

A

Left lung, accommodate for heart

34
Q

Auscultation of lungs

A

Posterior- 6 lung sounds
Lateral- 2 lung sounds each side
Anterior- 6 lung sounds

35
Q

Bronchial

A

Normal

Harsh, hollow, heard over trachea and larynx

36
Q

Vesicular

A

Normal

Rustling, low, soft sounds heard all over lung fields

37
Q

Bronchovesicular

A

Normal

Moderate pitch, heard over bronchi

38
Q

Wheezes

A

Adventitious
High pitched musical sound
Heard of expiration, over all lung fields
DOES NOT CLEAR WITH COUGH

39
Q

Crackles

A

Adventitious
Fine, high pitched crackling
“hair rubbing” sound
DOES NOT CLEAR WITH COUGH

40
Q

Rhonchi

A

Adventitious
Low pitch, rumbling
MAY CLEAR WITH COUGH

41
Q

Stridor

A

Serious airway obstruction

42
Q

Dimished/ tight./ absent

A

Ominous sign

43
Q

Auscultation of the heart

A 
A-2nd ICS
P-2nd ICS
E-3rd ICS
T-4th ICS
M-5 ICS
44
Q

Assessment order of abdomen

A

Inspect
Auscultation
Percussion
Palpate

45
Q

Which quadrant do you begin auscultating?

A

RLQ moving clockwise

46
Q

If no bowel sounds are heard…

A

Listen for 5 minutes

47
Q

Visceral pain

A

dull, poorly localized

48
Q

Parietal pain

A

sharp, localized

49
Q

Somatic pain

A

Muscles, tendons, bones

50
Q

What is a normal pulse

A

2+ normal

51
Q

What is considered a bounding pulse?

A

4+ bounding

Funds Test 2 (5 decks)

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