health assessment
A clinic nurse is preparing to evaluate the peripheral vision of a client by the confrontational method. Which statement demonstrates that the client correctly understands the instructions for the test?
"I will tell you when the small object is in my visual field."
PaCO2 normal range
35-45 mm Hg high levels pneumonia, asthma, COPD
Mini-Cog Test
Assesses dementia by having patients remember and repeat three common objects and draw a clock face indicating a particular time.
he nurse in a health care clinic is preparing to test a client for accommodation. Initially, the nurse should ask the client to take which action?
Focus on a distant object.
The nurse reviews the findings from a physical exam done on a client for ear or hearing disorders and notes documentation that the client has hyperacusis. Which would the nurse expect to note on assessment of the client?
Intolerance for sound levels that do not bother other people
A chest x-ray report states that the client has a left apical pneumothorax. The nurse caring for the client monitors the status of breath sounds in that area by placing the stethoscope at which location?
Just under the left clavicle
No p waves with ST elevation
Myocardial hypoxia
the 5 Ps
Pain Pulse Pallor Paresthesia Paralysis for a fracture
The nurse conducting a health screening is performing hearing assessments on clients. Senior nursing students are assisting the nurse with the assessments. The nurse instructs the students to perform a voice test by taking which action?
Stand 1 to 2 ft (30 to 60 cm) away from the client and ask the client to block 1 external ear canal.
The nurse is testing the extraocular movements in a client to assess for muscle weakness in the eyes. The nurse should implement which assessment technique to assess for muscle weakness in the eye?
Test the 6 cardinal positions of gaze.
The clinic nurse is preparing to perform a Romberg test on a client being seen in the clinic. The nurse would perform this test for the purpose of determining which status?
The Romberg test assesses the ability of the vestibular apparatus in the inner ear to help maintain standing balance. The Romberg test also assesses intactness of the cerebellum and proprioception.
Positive Brudzinski's sign
The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column.
The nurse is assessing a client suspected of having meningitis for meningeal irritation and elicits a positive Brudzinski's sign. Which finding did the nurse observe?
The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column.
pleural rub
scratchy sound produced by pleural surfaces rubbing against each other. characterized by sounds that are described as creaking, groaning, or grating.
external otitis
swimmers ear painful condition caused when irritating or infective agents come into contact with the skin of the external ear. Affected skin becomes red, swollen, and tender to touch or movement. Swelling of the ear canal narrows the canal and can lead t
confrontation test
tests peripheral vision
Astereognosis is the inability
to discern the form or configuration of common objects using the sense of touch.
The nurse is assessing for the presence of pallor in a dark-skinned client. What finding should the nurse look for?
Loss of normal red tones in the skin
Cranial Nerve 4: Trochlear
Motor nerve that moves the eyeball
Cranial Nerve 1
Olfactory
Cranial Nerve 2
Optic - vision
What action should the nurse take before drawing a sample for ABG from radial artery
Perform Allen test to assess collateral circulation Make the client's hand blanch by obliterating both the radial and the ulnar pulses, Then release the pressure over the ulnar artery only. If flow through the ulnar artery is good flushing will be seen. Allen test positive, radial artery can be used.
The nurse is performing an abdominal assessment on a client. The nurse determines that which finding should be reported to the primary health care provider (PHCP)?
Pulsation between the umbilicus and the pubis The presence of pulsation between the umbilicus and the pubis could indicate an abdominal aortic aneurysm and should be reporte
intentional tremor
Tremor occurs when pointing toward a target Associated with cerebellar dysfunction
A client has a nasogastric tube connected to low intermittent suction. When administering medications through the nasogastric tube, which action should the nurse do first?
Turn off the intermittent suction device
A conductive hearing loss occur
a result of a physical obstruction to the transmission of sound waves.A physical obstruction to the transmission of sound waves
After performing an initial abdominal assessment on a client, the nurse documents that the bowel sounds are normal. Which description bestdescribes normal bowel sounds?
Relatively high-pitched clicks or gurgles auscultated in all 4 quadrants
The nurse is performing a neurological assessment on a client with a head injury. The nurse should use which technique to assess the plantar reflex?
Stroking the foot from the heel to the toe
Cranial Nerve 5: Trigeminal
Funtion- facial sensation to hot/cold; light touch, chewing, branches: ophthalmis, maxiallry, mandibular Test- Respective testing of 3 divisions. C;inch jaw & check masseter & temporalis muscles; jaw and corneal reflex.
The nurse is performing a neurological assessment on a client who had a stroke (brain attack). The nurse checks for proprioception using which assessment technique?
Holding the sides of the client's great toe and, while moving it, asking what position it is in
The nurse is testing a client for astereognosis. The nurse should ask the client to close the eyes and perform which action?
Identify an object placed in the client's hand.
*Assessment order IP PA
Inspection Palpation Percussion Auscultation
Pronator drift occurs
when a client cannot maintain the hands in a supinated position with the arms extended and the eyes closed. This assessment may be done to detect small changes in muscle strength that might not otherwise be noted.
pack years
# of packs/day X # of years smoked
pH level
7.35-7.45
p02
80-100 low levels can indicate asthma, respiratory distress syndrome, cancer of the lungs High levels may indicate too much o2
While performing a cardiac assessment on a client with an incompetent heart valve, the nurse auscultates a murmur. The nurse documents the finding and describes the sound as which?
A blowing or swooshing noise
HCO3-
Bicarbonate 21-28
melena
Black tarry stool
The nurse should ask a client to take which action when testing the function of the spinal accessory nerve (CN XI)?
Elevate the shoulders
A heart murmur is an
abnormal heart sound and is described as a faint or loud blowing, swooshing sound with a high, medium, or low pitch. Lub-dub sounds are normal and represent the S1 (first) heart sound and S2 (second) heart sound, respectively.
Lordosis (swayback)
abnormal, inward curvature of a portion of the lower portion of the spine
amenorrhea
absence of menstruation
Cheyne-Stokes respiration
an irregular pattern of breathing characterized by alternating rapid or shallow respiration followed by slower respiration or apnea. Rhythmic respirations with periods of apnea
No P wave
atrial fibrillation
Clubbing of fingers
rounded fingertips due to the chronic in adequate oxygen to tissues
Cranial Nerve 10: Vagus
somatic motor impulses to larynx and pharynx (when you go to vagus you want to hear someone sing with their larynx ie. voice box)
orthopnea
difficulty breathing when lying down
hirsutism
excessive hair growth
Cranial Nerve 3: Oculomotor
eye movement (up and down), Pupil dilation
Cranial Nerve 7: Facial
facial expression
Cranial Nerve 8: Vestibulocochlear
hearing and balance
sensorineural hearing loss
hearing loss caused by damage to the cochlea's receptor cells or to the auditory nerves; also called nerve deafness
peaked T waves on EKG
hyperkalemia
Abdominal Assessment I A PE PA
inspection, auscultation, percussion, palpation
muscle atrophy
lack of muscle activity; reduces muscle size, tone, and power
Cranial Nerve 6: Abducens
lateral eye movement
flat affect (emotional flattening)
no signs of emotional expression
he nurse in the health care clinic is performing a neurological assessment and is testing the motor function of cranial nerve V (trigeminal nerve). Which technique should the nurse implement to test the motor function of this nerve?
Separate the client's jaw by pushing down on the chin.
fracture assessment
Abnormal positioning Crepitus Severe pain Edema Limited mobility
The nurse is performing a respiratory assessment and is auscultating the client's breath sounds. On auscultation, the nurse hears a grating and creaking type of sound. The nurse interprets this to mean that client has which type of sounds?
Pleural friction rub
A client is diagnosed with external otitis. Which finding would the nurse expect to note on assessment of the client?
Redness and swelling in the ear canal
Cranial Nerve 9: Glossopharyngeal
SENSORY: TASTE ON POSTERIOR ASPECT OF TONGUE E.G. BITTER AND SOUR INABILITY TO INDENTIFY SUBSTANCES MOTOR: GAG REFLEX, SWALLOWING E.G. TONGUE DEPRESSOR POSITIVE FOR INABILITY TO ELICIT GAG REFLEX
The nurse in the health care clinic is performing a neurological assessment and is testing the motor function of cranial nerve V (trigeminal nerve). Which technique should the nurse implement to test the motor function of this nerve?
Separate the client's jaw by pushing down on the chin.
The nurse is preparing to test the sensory function of cranial nerve V in a client. The nurse should obtain which item to test the sensory function of this nerve?
To assess the sensory function of cranial nerve V (the trigeminal nerve), the nurse would ask the client to close the eyes and then with a wisp of cotton lightly touch the client's forehead, cheeks, and chin, noting whether the touch is felt equally on both sides of the face
A positive Murphy's sign is best described as:
pain felt when taking a deep breath when the examiner's fingers are on the approximate location of the inflamed gallbladder
Homan's sign
pain in calf or popliteal region Pain with dorsiflexion of the foot
tactile fremitus
palpable vibration When assessing for tactile fremitus, the nurse should begin palpating over the lung apices in the supraclavicular area. The nurse should compare vibrations from 1 side to the other as the client repeats the word ninety-nine.
