Head to Toe Assessment

Question 1

Metformin

Answer 1

Biguanide

Question 2

Glipizide

Answer 2

Sulfonylureas

Question 3

Prandin or Starlix

Answer 3

Glinides

Question 4

Avandia

Answer 4

Thiazolidinediones

Question 5

Metformin onset

Answer 5

less than 1 hour

Question 6

Glipizide onset

Answer 6

15-30 min

Question 7

When obtaining data…

Answer 7

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

Question 8

Pre-orientation phase

Answer 8

Before you meet the patient

Gather information on them

Question 9

Orientation phase

Answer 9

Explain purpose of interview

• Establish nurse-patient interview
• Inspect apperance and behavior

Question 10

Working phase

Answer 10

Collect data regarding chief complaint

Question 11

Termination phase

Answer 11

Clue that the interview is coming to an end

summarize, give opportunity to ask questions

Question 12

Subjective data

Answer 12

What patient/family tells you

“Statement”

Question 13

Objective data

Answer 13

Findings with physical assessment
Diagnostic test results
“Observed”

Question 14

Detailed description of problem using open ended questions

Answer 14

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

Question 15

Mental Health Assessment

Answer 15

Appearance
Behavior
Cognition
Thought process

Question 16

Order of Physical Assessment

Answer 16

1. Inspect
2. Palpate
3. Percussion
4. Auscultate

Question 17

Transgential Lighting

Answer 17

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

Question 18

Used to assess pulse

Answer 18

Pads of fingers

Question 19

Used to assess temperature

Answer 19

Dorsal of hand

Question 20

Used to assess vibration

Answer 20

Palm of hand

Question 21

Light palpation

Answer 21

1cm in depth

Question 22

Deep palpation

Answer 22

4cm in depth

Question 23

Diaphragm of stethescope

Answer 23

Used to hear bowel and breath sounds

Question 24

Bell of stethescope

Answer 24

Low pitched

Extra heart and vascular sounds

Question 25

Before auscultating on a hairy chest..

Answer 25

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

Question 26

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

Answer 26

Sclera or inside mouth (gums)

Question 27

PERRLA

Answer 27

Pupils equal, round, responsive to light, and accomodate

Question 28

JVD

Answer 28

Jugular Vein Distention | May signal fluid volume excess

Question 29

Clubbing

Answer 29

Due to lack of oxygen to capillary nail beds | Can be due to smoking

Question 30

Turgor

Answer 30

Assesses skins elasticity | Tenting can be a result of dehydration

Question 31

Eupnea

Answer 31

Normal quiet respiration

Question 32

Which lung is shorter?

Answer 32

Right lung, to accommodate room for liver

Question 33

Which lung is narrower?

Answer 33

Left lung, accommodate for heart

Question 34

Auscultation of lungs

Answer 34

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

Question 35

Bronchial

Answer 35

Normal | Harsh, hollow, heard over trachea and larynx

Question 36

Vesicular

Answer 36

Normal | Rustling, low, soft sounds heard all over lung fields

Question 37

Bronchovesicular

Answer 37

Normal | Moderate pitch, heard over bronchi

Question 38

Wheezes

Answer 38

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

Question 39

Crackles

Answer 39

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

Question 40

Rhonchi

Answer 40

Adventitious Low pitch, rumbling MAY CLEAR WITH COUGH

Question 41

Stridor

Answer 41

Serious airway obstruction

Question 42

Dimished/ tight./ absent

Answer 42

Ominous sign

Question 43

Auscultation of the heart

Answer 43

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

Question 44

Assessment order of abdomen

Answer 44

Inspect Auscultation Percussion Palpate

Question 45

Which quadrant do you begin auscultating?

Answer 45

RLQ moving clockwise

Question 46

If no bowel sounds are heard...

Answer 46

Listen for 5 minutes

Question 47

Visceral pain

Answer 47

dull, poorly localized

Question 48

Parietal pain

Answer 48

sharp, localized

Question 49

Somatic pain

Answer 49

Muscles, tendons, bones

Question 50

What is a normal pulse

Answer 50

2+ normal

Question 51

What is considered a bounding pulse?

Answer 51

4+ bounding