Assessment

Question 0

Reg capillary refill?

Answer 0

Under two secs

Question 1

Nevus assess? ABCDE

Answer 1

asym, border irregularity, color variation, diameter >6mm, elevation enlargement

Question 2

When does clubbing of nails occur?

Answer 2

Oxygenation probs

Question 3

Assess LOC?

Answer 3

Times 3 person place time

Question 4

Micro/macrocephalic?

Answer 4

Small/big head

Question 5

Stuporous

Answer 5

Lack of critical cog function

Question 6

Comatose

Answer 6

Coma

Question 7

Sclera?

Answer 7

White of eye

Question 8

Conjunctiva?

Answer 8

Inside of eyelid

Question 9

Caries

Answer 9

Tooth decay

Question 10

Furrowed

Answer 10

Groove

Question 11

Mydriasis

Answer 11

Dilation

Question 12

Fixed and constricted

Answer 12

Miosis

Question 13

Bulging

Answer 13

Exopthalmus

Question 14

Strabismus?

Answer 14

Cross eyed

Question 15

Ptosis

Answer 15

Dropping of upper lid

Question 16

Ectropian

Answer 16

Lower lid is loose and rolling out

Question 17

Entropion

Answer 17

Lower lids roll in

Question 18

What are eyes PERRLA

Answer 18

Pupils equal round reactive to light accommodation

Question 19

Lymphadenopathy?

Answer 19

Enlargement due to infection or inflammation

Question 20

Scoliosis

Answer 20

S haped

Question 21

Kyphosis

Answer 21

Outward curve

Question 22

Lordosis

Answer 22

Increased lumbar curvature

Question 23

Tachyon era

Answer 23

More than 24

Question 24

Bradypnea

Answer 24

Under ten

Question 25

Melena

Answer 25

Black tarry stool

Question 26

Ataxia

Answer 26

Uncoordinated movements

Question 27

Pulse assessment

Answer 27

Rate rhythm quality sym

Question 28

Pain

Answer 28

Location Character Intensity Duration

Question 29

LOC ASSESSMENT

Answer 29

alertness orientation mood affect thought content coherence memory

Question 30

Speech assessment

Answer 30

Clarity

Question 31

Hair assessment

Answer 31

Texture distribution

Question 32

Facial expressions

Answer 32

Sym

Question 33

Cough assess

Answer 33

Type frequency secretions

Question 34

Nose

Answer 34

Latency secretion smell

Question 35

Resperations?

Answer 35

Rate rhythm depth exertion

Question 36

Breasts

Answer 36

Sym, nipples discharge

Question 37

Stool

Answer 37

Frequency consistency color

Question 38

Voiding pattern

Answer 38

Frequency force

Question 39

Norm temp range?

Answer 39

36-38

Question 40

What changes temperature?

Answer 40

Age, activity, hydration, state of health

Question 41

Reg heart rate?

Answer 41

60-100bpm

Question 42

Blood pressure regular?

Answer 42

120/80 or less pulse pressure 30-50

Question 43

Resp rate?

Answer 43

12-20 deep and reg

Question 44

Newborn/ unconscious pt temp?

Answer 44

Axilla

Question 45

Weak feeble and thready heart rate?

Answer 45

Pulse of low volume

Question 46

What does palpation look for?

Answer 46

Resistance, resilience,roughness, texture, temp, mobility

Question 47

What part of hand for Temp Vibration Everything else for palpation

Answer 47

Dorsal Palm Tips

Question 48

What does percussion detect?

Answer 48

Size Boarders Consistency of orgs

Question 49

Characteristics of auscultation?

Answer 49

Frequency Loudness Quality Duration

Question 50

General survey?

Answer 50

``` Review of primary health probs VS, height, weight, behaviour, appearance Notes Illness, hygiene skin and body image Emotional state, developmental status ```

Question 51

Why complete a head to toe assessment?

Answer 51

Identify norm Baseline for comparison Evaluate response for med or nursing intervention

Question 52

When can you complete a head to toe in acute care?

Answer 52

Admission, morning care

Question 53

When can you complete an assessment in lt care?

Answer 53

Upon admission or status change

Question 54

Head to toe in community?

Answer 54

With referral and PRN

Question 55

What do you auscultation for?

Answer 55

Heart rate breathing sounds

Question 56

What are all the systems?

Answer 56

``` Neurological Respiratory Cardiovascular GI Genito urinary and reproductive Musculoskeletal Integumentary and lymphatic ```

Question 57

What does a general survey include?

Answer 57

Physical appearance Body structures Mobility

Question 58

In a GS what would you observe about motility?

Answer 58

Gait, ROM

Question 59

In GS what would you observe about there appearance?

Answer 59

Age, sexually development LOC SKIN color Facial featurese

Question 60

In GS what would you observe about their body structure?

Answer 60

Stature nutrition symm posture position body build | Obv deformities

Question 61

What is the measurement of pain?

Answer 61

Subjective | Scale of 1-10 or descriptor scale