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skills exams > skills exam 3 > Flashcards

skills exam 3 Flashcards

1
Q

What does AVPU mean?

A 
It is a LOC scale
Awake and Alert
responds to Verbal stimuli
responds to Painful stimuli
Unconscious
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2
Q

What does the Glasgow coma scale evaluate?

A 
Eye opening response
Verbal response
Motor response
Evaluates on a scale from 1 to 5, 15 is the best
"less than 8, intubate"
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3
Q

What are the four parts of orientation?

A

Person, place, time, situation

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4
Q

What does PERLLA mean?

A

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

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5
Q

What is aphasia?

A

Inability to communicate

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6
Q

What is EENT?

A

Inspect in order, Ears Eyes Nose and then Throat

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7
Q

What is tachypnea?

A

Respirations >20

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8
Q

What is bradypnea?

A

Respirations <12

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9
Q

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

A

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

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10
Q

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

A

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

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11
Q

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

A

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

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12
Q

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

A

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

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13
Q

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

A

They are faint lung sounds caused by decreased air movement

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14
Q

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

A

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

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15
Q

What is hemoptysis?

A

Blood in sputum

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16
Q

What are S1 and S2?

A

Heart sounds. Lub and then dub

17
Q

When do you listen to apical pulse?

A

If heart rate or rhythm are outside normal finding expectations

18
Q

How do you find the apical pulse?

A
  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
19
Q

How do you determine pulse deficit?

A

Measure apical and radial pulse simultaneously

20
Q

What are normoactive bowl sounds?

A

Clicks and gurgles that occur 5 to 34 per minute

21
Q

What are hypoactive bowel sounds?

A

Bowels sounds 3 to 5 times per minute

22
Q

What are hyperactive bowel sounds?

A

Greater than 34 times per minute

23
Q

When are absent bowel sounds established?

A

After 5 minutes of listening in one quadrant

24
Q

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

A

At least once per shift

25
Q

What are the four pitting edema categories?

A

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

26
Q

What are the four different pulse strengths?

A

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

27
Q

Where is the popliteal pulse?

A

Back of the knee

28
Q

What is deep rubor?

A

Purplish/reddish color, indicates peripheral vascular disease

29
Q

What are the 6 P’s of neurovascular assessment?

A
  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)
30
Q

What is the difference between active and passive ROM?

A

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

31
Q

What is the difference between full and partial ROM?

A

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

32
Q

What are 6 ADLs?

A
  1. Bathing self
  2. Dressing self
  3. Feeding self
  4. Toileting
  5. Brushing hair
  6. Brushing teeth
33
Q

How often is safety documented?

A

Every 2 hours

34
Q

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

A

High calorie and high protein

35
Q

What is atelectasis?

A

Hardening of lung tissues/collapsed lung

skills exams (7 decks)

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