head to toe assessment power point

Question 1

first steps of physical assessment

Answer 1

overall physical apperance
acute signs of distress
age and physical development
gender/ ethnicity

Question 2

general survey include______,________,_______

Answer 2

vital signs
hight and weight
orientation

Question 3

assessment of mental status includes

Answer 3

appearance
speech
affect
orientation
level of consciousness
abstract reasoning- ability to solve problem
memory

Question 4

assess appearance to determine_____ ____ ________, ______, _____

Answer 4

level of functioning
hygiene
grooming

Question 5

what is affect

Answer 5

refers to the external expression of emotion

Question 6

what is assess

Answer 6

appropriate for situation

Question 7

example of affect

Answer 7

inappropriate affect would be laughing at sad story

Question 8

assessing speech include looking for

Answer 8

clarity
word choice
rate of speech
any unusual patterns

Question 9

when assessing speech ask yourself these two questions

Answer 9

do they speak in 2-3 word sentences
do they use high level of vocabulary

Question 10

when assessing orientation ask person 4 questions

Answer 10

persons name
where they at
what time is it
what what is the situation

Question 11

abstract reasoning is

Answer 11

the ability to think at higher level than a child

Question 12

example of abstract reasoning

Answer 12

ask patient to interpret a riddle

Question 13

abstract reasoning is reported as

Answer 13

intact or not intact

Question 14

memory types

Answer 14

short term memory
long term memory

Question 15

to test short term memory you should

Answer 15

tell patient 3 words

and have them repeat the objects the way you tell them

Question 16

to assess long-term memory you should

Answer 16

ask the patient a question about an event that most people would know that happened years ago

Question 17

levels of consciousness

Answer 17

awake and alert

lethargic or somnolent (lack of energy, sluggish)

obtunded (mentally dulled)

stupor semicoma or comatose (sleeping most of time lack critical cognitive function and lack of conscious)

coma

Question 18

lethargic or somnolent meaning

Answer 18

lack of energy, sluggish

Question 19

obtunded meaning

Answer 19

mentally dull

Question 20

stupor semicome or comatose meaning

Answer 20

sleepig most of the time: lack of critical cognitive function and lack of consious

Question 21

what scale is used to determine level of function

Answer 21

Glasgow coma scale

Question 22

determining level of consiousness using glawgow coma scale assess 3 areas

Answer 22

eye-opening
best verbal respose
best motor response

Question 23

eye-opening grade scoring

Answer 23

4 spontaneously
3 on request
2 to painful stomuli
1 no response

Question 24

best verbal response grade scoring

Answer 24

5 oriented to time place and knows himself
4 confused
3 inappropriate words
2 incomprehensible sounds
1 no response

Question 25

best motor response grade scale

Answer 25

6 obey commands 5 localizes (orient locally) to painful stimulus 4 withdraws from pain 3 flexed extremities- decorticate 2 extended extermities- decerebrate 1 no response

Question 26

how is the final grade in Glasgow coma scale graded

Answer 26

add togather all areas

Question 27

score total meaning in Glasgow coma scale

Answer 27

15 is normal 7 indicates a coma 3 is brain dead

Question 28

assessment include

Answer 28

inspection palpation auscultation and percussion

Question 29

assessing the head

Answer 29

size symmetry position movement of head neck and face palpate the skull: look for tenderness, masses, redness, pus, drainage

Question 30

assessment of head

Answer 30

any redness or skin discoloration decreased or increased tremor (shaking) asymmetry facial expressions palpate the temporomandibular joint function and note abnormalites

Question 31

assessing the eyes

Answer 31

look for lumps, redness, swelling pain inspect the eyelids and eyelashes inspect the lacrimal (tear) ducts and glands assess extraocular movement inspect the conjucativae

Question 32

how to assess extraocular movement

Answer 32

tell patient to only follow your finger with their eyes move your index finger in the shape of a cross then diagonally

Question 33

when inspecting conjunctivae red means_____ or _____, pus means ______ pale is _____

Answer 33

allergy, infection, infection, anemia

Question 34

eye exam cont

Answer 34

PERRLA both pupils should dilate in dark and constrict in light test pupil accommodation inspect the lens

Question 35

PERRLA stands for

Answer 35

pupils equal, round, reactive to light, and accommodation

Question 36

how to test pupil accommodation

Answer 36

move your finger/ penlight from 12 inches to 1 inch away toward the eye. the eyes should accommodate to the change in the distance by almost being crossed any variations may mean a head injury

Question 37

The Snellen char and eye exam test for

Answer 37

acuity of distance and vision

Question 38

how to use Snellen eye chart

Answer 38

whatever line the patient can easily read is your vision the top line is 20/200 which means you can read at 20 feet what everyone else can read at 200 feet bottom line is 20/20 which means you can read at 20 feet what normal vision people can read at 20 feet

Question 39

ear examination

Answer 39

inspect the external ear shape size symmetry look for drainage test hearing by using the whisper test

Question 40

how does the whisper test work

Answer 40

stand behind the patient and whisper and ask if he hear and understood what you said

Question 41

tuning fork test has two types

Answer 41

Weber test Rinne test

Question 42

how to do Rinne test

Answer 42

strike the tuning fork and place it In the air in front of the ear, this tests air conduction which should best heard twice as long as the sound from bone condition. then strike the tuning fork and lace it on the mastoid bone behind the ear. the bone conduction sound should only be heard half the amount of time as the air conduction sound

Question 42

how to do Weber test

Answer 42

place tuning fork midline on the skull and as if the tone is equal bilaterally or better in one ear

Question 43

meaning of weber test

Answer 43

if a patient hears better on one side it means that the ear that head the sounds the longest is the worn out or bad ear

Question 44

meaning of Rinne test

Answer 44

air conduction is better than bone conduction, which is what would be expected in a healthy individual

Question 45

assessing the noes and sinuses

Answer 45

inspect the external noes for discoloration, lumps, and asymmetry check patency of nasal passages by closing off one nostril and having them blow. if no air pressure the nose isn't patent or open inspect the internal structure for deviation or redness or pallor palpate the external structures palpate the frontal and maxillary sinuses for pain

Question 46

assessing mouth and throat

Answer 46

inspect the lips for symmetry and color inspect oral mucosa and gums for color inspect the teeth for cavities or if missing teeth or false teeth inspect the tongue for dryness, grooves, white patches that don't brush off are thrush (candida) check under the tongue for sores or masses inspect the oropharynx (back of mouth). do they have tonsils are the swollen or have pus is the uvula midline (if not may be a stroke or abscess) test gag reflex with a tongue blade or sip water

Question 47

blue lips mean

Answer 47

cyanosis or lack of oxygen

Question 48

dry lips mean

Answer 48

dehydration

Question 49

oral mucosa and gums color should be

Answer 49

pink

Question 50

if oral mucosa or gums color are red or pale check for

Answer 50

drainage or bleeding

Question 51

edentulous teeth mean

Answer 51

missing all teeth

Question 52

most common site for oral cancer is

Answer 52

under tongue

Question 53

if uvula is not midline what does it mean

Answer 53

could mean a stroke or abscess

Question 54

if you have a questioning attitude check

Answer 54

current and past patent history ask about current medication

Question 55

when do you document your finding

Answer 55

at the time of the assessment

Question 56

inspecting the neck

Answer 56

palpate the cervical lymph nodes palpate the thyroid

Question 57

thyroid pulse should

Answer 57

not be felt it abnormal