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S2025 ABSN NUR 323 Health Assessment and Psychomotor Skills I > Physical Assessment I > Flashcards

Physical Assessment I Flashcards

1
Q

If a tonsil is visible, the nurse would document a grade of…

A

1+

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2
Q

If a tonsil is halfway between the tonsillar pillars and uvula, the nurse would document a grade of…

A

2+

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3
Q

If a tonsil is touching the uvula, the nurse would document a grade of…

A

3+

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4
Q

If a tonsils are touching or “kissing” the other, the nurse would document a grade of…

A

4+

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5
Q

A whispered voice assessment tests for…

A

gross hearing

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6
Q

The Weber and Rinne tuning fork test measures…

A

hearing by air conduction/bone conduction in which the sound vibrates through the cranial bones to the inner ear

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7
Q

The Snellen chart measures…

A

visual acuity

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8
Q

The Confrontation Test measures…

A

peripheral vision

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9
Q

The Diagnostic Positions Test measures…

A

EOM’s

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10
Q

Nystagmus is defined as

A

a fine oscillating movement of the eye. expected when assessed at extreme lateral gazes.

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11
Q

Consensual response of the pupil means…

A

simultaneous constriction of the other pupil when a light is shined in the eye.

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12
Q

When assessing accommodation of the eye the expected response would be…

A

pupillary constriction and convergence of the axes of the eyes

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13
Q

The acronym PERRLA means…

A

pupils equal, round, reactive to light, and accommodation

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14
Q

Define flexion:

A

bending a limb at a joint

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15
Q

Define extension:

A

straightening a limb at a joint

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16
Q

Define abduction:

A

moving a limb away from the bodies midline

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17
Q

Define adduction:

A

moving a limb toward the bodies midline

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18
Q

Define pronation:

A

turning the forearm so the palm is down

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19
Q

Define supination:

A

turning the forearm so the palm is up: think holding a can of soup

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20
Q

Define inversion:

A

moving the sole of the foot inward at the ankle

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21
Q

Define eversion:

A

moving the sole of the foot outward at the ankle

22
Q

Define rotation:

A

moving the head around a central axis

23
Q

Define crepitation:

A

an audible and palpable crunching or grating that occurs with movement of the joint

24
Q

Define crack:

A

heard as a tendon or ligament slips over the bone during motion

25
Q

Define scoliosis:

A

lateral S shaped curvature of the spine

26
Q

Define kyphosis:

A

enhanced thoracic curve: think Hunchback of Notre Dame

27
Q

Define lordosis:

A

pronounced lumbar curve: think pregnancy or obesity

28
Q

If muscle strength is described as “full ROM against gravity, full resistance,” the nurse would document this as a…

A

Grade 5

29
Q

If muscle strength is described as “full ROM against gravity, some resistance” the nurse would document this as a…

A

Grade 4

30
Q

If muscle strength is described as “Full ROM with gravity” the nurse would document this as a…

A

Grade 3

31
Q

If muscle strength is described as “Full ROM with passive motion” the nurse would document this as a…

A

Grade 2

32
Q

If muscle strength is described as “slight contraction” the nurse would document this as a…

A

Grade 1

33
Q

If muscle strength is described as “no contraction” the nurse would document this as a…

A

Grade 0

34
Q

The order of examination for the musculoskeletal system is…

A

Inspection, Palpation, Range of Motion, and Muscle Testing

35
Q

Define active range of motion.

A

The range of motion that can be achieved when opposing muscles contract and relax, resulting in joint movement. The patient can complete ROM without help.

36
Q

Define passive range of motion.

A

The space in which a part of your body can move when someone or something is creating the movement. Such as movement of a joint with physical therapy. The patient has assistance.

37
Q

Define circumduction.

A

Moving a joint in a circle.

38
Q

Techniques used in physical assessment are completed in the following order for patient safety and comfort.

A
  1. Inspection
  2. Palpation
  3. Percussion
  4. Auscultation
39
Q

Techniques used for the abdominal assessment are always completed in this order.

A
  1. Inspection
  2. Auscultation
  3. Percussion
  4. Palpation
40
Q

Pulses are graded on a scale of 0-4+
Identify the scale

A

4+ Bounding
3+ Increased
2+ Expected finding
1+ Weak
0 Absent

41
Q

Define the acronym ABCDEE for assessing skin lesions

A

A-Assymetry
B-Border irregularity
C-Color
D-Diameter <6mm
E-Evolution
E-Elevation

42
Q

Define 1+ edema

A

mild pitting; slight indentation; no perceptible swelling of the leg

43
Q

Define 2+ edema

A

Moderate pitting. indentation subsides rapidly

44
Q

Define 3+ edema

A

Deep pitting; indentation remains for a short time; leg looks swollen

45
Q

Define 4+ edema

A

Very deep pitting; indentation lasts a long time; leg is grossly swollen and distorted

46
Q

Define alert

A

Awake or readily aroused, oriented, fully aware of all stimuli

47
Q

Define lethargic

A

Not fully alert, drifts off to sleep when not stimulated

48
Q

Define obtunded

A

Sleeps most of the time. difficult to arouse

49
Q

Define Stupor or Semi-coma

A

Spontaneously unconscious, responds only to vigorous shake or pain

50
Q

Define coma

A

completely unconscious. makes no response to pain or to stimuli

S2025 ABSN NUR 323 Health Assessment and Psychomotor Skills I (6 decks)

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