skills exam 3

Question 1

What does AVPU mean?

Answer 1

It is a LOC scale
Awake and Alert
responds to Verbal stimuli
responds to Painful stimuli
Unconscious

Question 2

What does the Glasgow coma scale evaluate?

Answer 2

Eye opening response
Verbal response
Motor response
Evaluates on a scale from 1 to 5, 15 is the best
"less than 8, intubate"

Question 3

What are the four parts of orientation?

Answer 3

Person, place, time, situation

Question 4

What does PERLLA mean?

Answer 4

Pupils Equal Round Reactive to Light with Accommodation present (and consensual response)

Question 5

What is aphasia?

Answer 5

Inability to communicate

Question 6

What is EENT?

Answer 6

Inspect in order, Ears Eyes Nose and then Throat

Question 7

What is tachypnea?

Answer 7

Respirations >20

Question 8

What is bradypnea?

Answer 8

Respirations <12

Question 9

What do coarse crackles sound like and what are they caused by?

Answer 9

Moist bubbling sound, heard on inspiration or expiration, caused by fluid in airways

Question 10

What do fine crackles sound like and what are they caused by?

Answer 10

Velcro being torn apart, heard at the end of inspiration, caused by alveoli popping open on the end of inspiration

Question 11

What does stridor sound like and what is it caused by?

Answer 11

Loud crowing noise/dinosaurs heard without stethoscope, caused by airway obstruction

Question 12

What do wheezes sound like and what are they caused by?

Answer 12

Find high pitched violins mostly on expiration, caused by narrowed airways

Question 13

What are diminished lung sounds and what are they caused by?

Answer 13

They are faint lung sounds caused by decreased air movement

Question 14

What do rhonchi sound like and what are they caused by?

Answer 14

Low pitched rattling sound, similar to snoring, caused by lung obstruction or secretions

Question 15

What is hemoptysis?

Answer 15

Blood in sputum

Question 16

What are S1 and S2?

Answer 16

Heart sounds. Lub and then dub

Question 17

When do you listen to apical pulse?

Answer 17

If heart rate or rhythm are outside normal finding expectations

Question 18

How do you find the apical pulse?

Answer 18

1. Have the patient lay donw
2. Find the sternal notch (in between the clavicles)
3. Find the angle of louis below the sternal notch (chest midline)
4. Move your hand slightly to their left side and start to count intercostal spaces (begin at space #2)
5. Once you find the fifth intercostal space, place the hand so that it is midclavicle
6. Place your stethoscope there and listen for 60 seconds

Question 19

How do you determine pulse deficit?

Answer 19

Measure apical and radial pulse simultaneously

Question 20

What are normoactive bowl sounds?

Answer 20

Clicks and gurgles that occur 5 to 34 per minute

Question 21

What are hypoactive bowel sounds?

Answer 21

Bowels sounds 3 to 5 times per minute

Question 22

What are hyperactive bowel sounds?

Answer 22

Greater than 34 times per minute

Question 23

When are absent bowel sounds established?

Answer 23

After 5 minutes of listening in one quadrant

Question 24

If a patient is incontinent, has progressed dementia, dependent, or has an indwelling catheter, how often do you clean the perineal area?

Answer 24

At least once per shift

Question 25

What are the four pitting edema categories?

Answer 25

Mild: +1, depression disappears rapidly Moderate: 2+, depression disappears in 10-15 seconds Moderately Severe: 3+, depression disappears in about a minute Severe: 4+, depression can last for more than 2 minutes

Question 26

What are the four different pulse strengths?

Answer 26

0: absent, medical emergency Weak: 1+, diminished, barely palpable (peripheral vascular disease or decreased cardiac output) Strong: 2+, normal findings Bounding: 3+, full, fluid volume overload

Question 27

Where is the popliteal pulse?

Answer 27

Back of the knee

Question 28

What is deep rubor?

Answer 28

Purplish/reddish color, indicates peripheral vascular disease

Question 29

What are the 6 P's of neurovascular assessment?

Answer 29

1. Pain 2. Paresthesia (tingling, pins and needles) 3. Pallor 4. Paralysis 5. Pulselessness 6. Poikilothermia (a limb that feels cooler than the others, no temperature regulation which is a circulation problem)

Question 30

What is the difference between active and passive ROM?

Answer 30

Active: patient can move extremities on their own Passive: patient cannot move extremities on their own

Question 31

What is the difference between full and partial ROM?

Answer 31

Full: extremities have no limitations on movement Partial: extremities have limitations on movement, can only move to a particular position and resistance noted

Question 32

What are 6 ADLs?

Answer 32

1. Bathing self 2. Dressing self 3. Feeding self 4. Toileting 5. Brushing hair 6. Brushing teeth

Question 33

How often is safety documented?

Answer 33

Every 2 hours

Question 34

What type of diet should you implement on an immobile patient?

Answer 34

High calorie and high protein

Question 35

What is atelectasis?

Answer 35

Hardening of lung tissues/collapsed lung