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Nursing > Head to Toe Assessment Questions > Flashcards

Head to Toe Assessment Questions Flashcards

1
Q

Adduction

A

Movement toward the midline

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2
Q

Abduction

A

Movement away from the body

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3
Q

Supination

A

Palms upward

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4
Q

Pronation

A

palms downward

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5
Q

Flexion

A

Decreasing the angle of a joint

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6
Q

Extension

A

increasing the angle of a joint

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7
Q

Inversion

A

Feet turned inward

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8
Q

Eversion

A

Feet turned outward

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9
Q

Lordosis

A

“Swayback”: Increased lumbar curvature above buttocks most often found in young children. neuromuscular problem with hip or posture

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10
Q

Scoliosis

A

Lateral curvature of the spine. Begin screening for this from 11-14 and treatment at 40 degree curvature.

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11
Q

Kyphosis

A

Exaggeration of the posterior thoracic spine curvature which can be due to osteoporosis (hunched Back)

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12
Q

Romberg Test

A

Has a patient stand still with eyes open, then with eyes closed. Tests their balance

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13
Q

Wheeze

A

Continuous musical sounds

Caused by high velocity airflow through significantly narrowed airways

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14
Q

Stridor

A

Harsh honking wheeze with severe bronchospasm

Air passing through a very constricted airway. Secondary to croup or a swallowed object caught in the airway

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15
Q

Crackles

A

Fluid in the lungs. Bubbling sounds. Not cleared with coughing

Common in the lower lung lobes

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16
Q

Rhonchi

A

Loud, Low pitched, Rumbling course sounds heard throughout lungs.

Typically secondary to mucus/fluid in larger airways. May be cleared with coughing

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17
Q

Chest Excursion

A

Holding hands on the back while the person breathes and seeing what happens to your hands. They should expand equally

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18
Q

Vocal Fremitus

A

External vibration while a pt talks. (the 99 test)

Lack of vibration may be due to: Accumulation of mucus, Lung Collapse, Lung lesion

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19
Q

Cheyne-Stokes

A

Alternating periods of deep rapid breathing followed by periods of apnea.
Associated with end-of-life

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20
Q

Biots Respirations

A

Irregular breathing pattern characterized by varying shallow respirations followed by periods of apnea
Associated with intracranial pressure and respiratory compromise.

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21
Q

Kussmal Respirations

A

A type of hyperventilation marked by exaggerated deep, regular, rapid breathing.

Normal with exercise

May be present with: aspirin (asa) overdose, pain, fever, hysteria, cardiac and or respiratory disease, Diabetic Ketoacidosis

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22
Q

ABCDE

A

Test for abnormal mole: Asymmetrical, Border, Color (black? dark brown? changing?), Diameter (no more than 6mm), Evolution

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23
Q

Braden Scale Range

A

6-23. Lower=higher risk for pressure injury

24
Q

Braden Scale Purpose

A

Assigns a number for the likelihood of developing a pressure injury

25
Q

Cranial Nerve 1 (Name, Function, and Sensory or Motor)

A

Olfactory: Sensory: Sense of smell: test with a scent under the nose

26
Q

Cranial Nerve 2 (Name, Function, and Sensory or Motor)

A

Optic: sensory: visual acuity: test with the snellen chart

27
Q

Cranial Nerve 3 (Name, Function, and Sensory or Motor)

A

Oculomotor: Motor: Extra ocular movement: Pupil Dilation: test with PERRLA

28
Q

Cranial Nerve 4 (Name, Function, and Sensory or Motor)

A

Trochlear: Motor: Up/down eye movement: test with 6 fields gaze

29
Q

Cranial Nerve 5 (Name, Function, and Sensory or Motor)

A

Trigeminal: motor + sensory: jaw movement + feeling in face: test with a cottonball to the face and clenching jaw

30
Q

Cranial Nerve 6 (Name, Function, and Sensory or Motor)

A

Abducens: motor: lateral eye movement: test with 6 fields gaze test

31
Q

Cranial Nerve 7 (Name, Function, and Sensory or Motor)

A

Facial: sensory + motor: taste on front of tongue + facial expression: test by smiling and tasting

32
Q

Cranial Nerve 8 (Name, Function, and Sensory or Motor)

A

Auditory: Sensory: Hearing: Test with the whisper test

33
Q

Cranial Nerve 9 (Name, Function, and Sensory or Motor)

A

Glossopharyngeal: Sensory + Motor: Gag reflex and taste on the back of the tongue: test by tasting

34
Q

Cranial Nerve 10 (Name, Function, and Sensory or Motor)

A

Vagus: Sensory + Motor: swallowing/movement of vocal cords: test by swallowing

35
Q

Cranial Nerve 11 (Name, Function, and Sensory or Motor)

A

Spinal Accessory: Motor: movement of head and shoulders: test by having pt. move head and shoulders

36
Q

Cranial Nerve 12 (Name, Function, and Sensory or Motor)

A

Hypoglosseal: Motor: Positioning of the tongue: Test by moving the tongue

37
Q

Glasgow Coma Scale (ranges and tests)

A

Objective numerical scale measuring level of conscience

Range: 3-15

Eye-Opening: 1-4
Verbal Response: 1-5
Motor Response: 1-6

38
Q

Enuresis

A

Bed wetting

39
Q

Hematuria

A

Blood in the urine

40
Q

polyuria

A

excessive urination (more than 2500-3000mL/24h)

41
Q

pyuria

A

pus in urine

42
Q

nocturia

A

Awakens at night to urinate a lot

43
Q

stress incontinence

A

Urination when the bladder receives stress (laughter, pressing on the bladder, shock)

44
Q

One organ in the RUQ

A

Liver & Gallbladder

45
Q

One organ in the LUQ

A

Stomach & Spleen

46
Q

One organ in the RLQ

A

Appendix

47
Q

One organ in the LLQ

A

Sigmoid Colon, left ovary, Left ureter

48
Q

Ptosis

A

Drooping of the eyelid

49
Q

Strabismus

A

Cross-eyed

50
Q

Exophthalmos

A

Bulging of the Eyes

51
Q

Myopia

A

Nearsightedness

52
Q

Hyperopia

A

Far sightedness

53
Q

Presbyopia

A

Age-related loss of near vision

54
Q

Allen’s Test

A

The Allen’s test ensures that the ulnar pulse and radial pulses are both working properly

55
Q

Pulse Deficit

A

Palpate radial while listening to apical pulse. If there is a difference, then the pulse is not reaching the peripheral pulse

56
Q

Clubbing

A

Indicative of inadequate blood flow to the hands. No space between fingernails when they are pressed together.

57
Q

Four Heart Valves

A

Aortic, Pulmonic, Tricuspid, Mitral

Nursing (17 decks)

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