Lab Final

Question 1

Heath history

Answer 1

Neuro
HEENT
Respiratory
Cardiac
Peripheral
Abdominal
Musculoskeletal
Integument

Question 2

General survey

Answer 2

Appearance-Alert, appears their age, even skin color, in tact
Body structure
Mobility behavior-no crutches or wheelchair

Question 3

Obtain vitals

Answer 3

Electronic monitor- temp, radial pulse, respirate rate, oxygen, blood pressure

Any pain???

Question 4

Mental status
Neuro 1

Answer 4

Patient is alert..
Name?
Where are you?
Why are you here?
Year?

Rate-4

Question 5

Perrla
Neuro 2

Answer 5

Assess pupils response bilateral
Pupil
Equal
Round
React to light
L
Accommodation

Assess for light reaction (hand between eyes)
Accommodation: (bring pen to and from face) eyes should follow

Question 6

Sensation
Neuro 3

Answer 6

Cotton ball on face, upper extremities and lower extremities

Question 7

Hearing
Neuro 4

Answer 7

Whisper behind them with one ear covered..(3 words)

Question 8

DTRS
Neuro 5

Answer 8

Test knee reflex- rate 1 or 2
Babinski- outline J on foot
(Positive Babinski seen on babies is when toes fan instead of curl)

Question 9

HEENT 1
Palpate head

Answer 9

No bumps, no tenderness, even hair distribution

Question 10

Face
HEENT 2

Answer 10

Face is symmetrical, nose midline, structures are aligned

Question 11

Oral
HEENT 3

Answer 11

Using light to assess mucous membrane
Uvula-midline
Soft palate- rises

Question 12

Enlarged lymph nodes
HEENT 5

Answer 12

Palpate 2 lymph sites

Question 13

Assess for symmetry
Respiratory 1

Answer 13

Describe AP to transverse chest configuration 1:2
Chest expansion: feel for C7..down to C10..hold hands flat and have them breathe

Question 14

Capillary refill
Respiratory 2

Answer 14

Capillary refill: less than 2 seconds
Check for clubbing: 160 or less
Cyanosis: blue coloring in nails, lips, fingers

Question 15

Breath sound
Respiratory 3

Answer 15

Bronchial-high pitched
Bronchovesicular- moderate pitch
Vesicular-low pitch

Question 16

Auscultate
Respiratory 4

Answer 16

Anterior-6
Lateral-right lobe, 5th rib
Posterior-10

Ladder pattern
Describe lung sounds

Question 17

Assess chest
Cardiac 1

Answer 17

Explain precordium for lifts/heaves/pulsations

Question 18

Assess for JVD
Cardiac 2

Answer 18

Lay flat, no pillow, have client face the left..raise bed

30-45 degrees

Question 19

Assess carotid
Cardiac 3

Answer 19

Palpate bilateral
Auscultate with bell

Question 20

Auscultate apical pulse
Cardiac 4

Answer 20

5 to 6th intercoastal, mid-clavicle
Listen for 60 seconds
Regular rate
Normal rhythm

Question 21

Identify and Auscultate heart sounds
Cardiac 5

Answer 21

Z pattern…
Aortic:
Pulmonic:
Erbs:
Tricuspid:
Mitral:
Bell for murmurs

Question 22

Identify 2 peripheral pulse sites
Peripheral cardio 1

Answer 22

Radial and brachial

Question 23

Identify 4 lower peripheral pulses
Peripheral cardiac 2

Answer 23

Femoral, popliteal, posterior tibia, dorsalis pedis

Question 24

Assess radial pulse
Peripheral cardiac 3

Answer 24

Assess radial- bilateral
Grade radial pulse-2 normal rhythm

Question 25

Assess dorsal is pedis Peripheral cardiac 4

Answer 25

Assess dorsal is pulse: bilateral grade: 1 or 2 normal rhythm.

Question 26

Edema Peripheral 5

Answer 26

No edema

Question 27

Abdomen 1

Answer 27

Inspect- convex, distended umbilicus, midline Auscultate-RLQ, RUQ, LUQ, LLQ Percussion Palpate

Question 28

Abdominal 2

Answer 28

Aortic, iliac, femoral arteries-no bruits (brewes) using the Bell.

Question 29

Assess gait Musculoskeletal 1

Answer 29

Get up and go test Romberg test-balance…stay with client for safety

Question 30

Upper extremities strength Muscular 2

Answer 30

Assess and and grade upper extremities bilateral Grade:

Question 31

Lower extremities strength Muscle 3

Answer 31

Assess and grade lower extremities bilateral Grade:

Question 32

Assess ROM upper Muscles 4

Answer 32

Flexion, extension, abduction, adduction, external rotation, internal rotation, circumduction Elbow: flexion, extension, supination, pronation Wrist: flexion, extension, inversion, eversion

Question 33

Assess ROM lower Muscles 5

Answer 33

Flexion, extension, abduction, adduction, external rotation, interval rotation Knee: flexion, extension , shallow knee bend, step walking Ankle: dorsiflexion, plantar flexion, inversion, eversion

Question 34

Assess skin color Integumentary 1

Answer 34

Skin color; even skin tone No bumps, lesions, even hair distribution

Question 35

Palpate skin upper and lower Integumentary 2

Answer 35

Warm temperature Moist skin Turgors