NLNPhysicalAssessment Flashcards

NLN Physical AssessmentStudy this se t online at: http://www.cram.com/cards/2664904

Adjust the opthalmoscope to a____________________________ andset the diopter dial to __________.

plain white circle0

Blood pressure should betaken in both arms when?

on f irst encounter, use highernumber arm for recording

Check extraocularmovements by

six cardinal directionsusing H pattern

Corneal ref lect ion should be centered____________________ when you shine a

light direct ly in f ront of the pat ientcentered over the pupils

Extraocular movement testswhich of the cranial nerves

3, 4, and 6oculomotor, trochlear, abducens

Frontal sinuses are located_________________ below eyebrows

Gait would fall under the category of

A) appearanceB) body s tructure

C) behaviorB) body structure

Head circumference ismeasured until age ______. 36 months


Height - measure in recumbantposition for ages _____.

under 2 (up to 3 ifunable to stand)

Hold otoscope with thumb & f ingersso that __________ aspect of yourhand makes contact with patient ulnar

Inspection look at color, shape,symmetry, position

Integumentary system -inspect skin for

color, moisture, hair pattern,rashes, lesions, edema, pallor

Look through the opthalmoscope and shine thelight into the patient's eye from about

_____________ away. You should see the retinaas a ________________.

2 feetred reflex

Maxillary sinuses are located_____________________ below zygomatic arch

Normal respirations 14-20 breaths/minute

Normal temperaturesOral -

98.6F/37C

+1 for rectal & aural, -1 for axillary


Objective data observed by nurse

Palpate lymph nodeswith _________

pads of your index andmiddle finger

Palpate skin for temperature, turgor,lesions, edema

Position patient at 20 feet for ______________chart

or at 14 feet for ___________________ pocketcard.

SnellenRosenbaum

Pull ear ______ and_________ for adult up and backPull ear ______ and_________ for child down and back

Sound characteristics ofauscultation

frequency, pitch intensity,duration, quality

Sounds are audiblewithout stethoscope direct auscultation


Stand 2 feet in front o f patient & have them look in to youreyes

Hold your hands to the s ide ha l f way between you and patientWigg le fingers on one hand

As k patient to ind ica te which s ide they s ee your fingers m ove.Th is is s creens _____________________________________

Visual fields byconfrontation

Subjective data said by clientThe __________________________ of lymph

nodes lies below the sternomastoid muscle andcannot be palpated without

_____________________________________.

deep cervical chaingetting underneath the muscle

To assess temporomandibular joint place the________________________________ directly in

front of the ________________ of each_____________.

t ips of your index f ingerstragus

ear

To percuss the chesthyperextend the ____________ finger of one handand place the _____________________________

firmly against the patient's chest.

middledistal interphalangeal joint

To test visual acuity the patientshould/should not wear glasses shouldUse _______ to assess

skin temperature back of hand (dorsal)

Use ___________ to assesstexture, moisture, areas of

tenderness fingertips


Use the end or the pad of theopposite middle f inger to f lick with

when percussing the chest. endUse your left hand and left eye to examine the

patient's _____ eye. Use your right hand and righteye to examine the patient's ______ eye.

leftright

Uses stethoscope indirect auscultation

Vitals at 1 yrPulse

Systolic BP11590

Vitals at 10 yrPulse

Systolic BP95105

Vitals at 2 yrPulse

Systolic BP11092

Vitals at 6 yrPulse

Systolic BP10395

Vitals at 6moPulse

Systolic BP13090


Vitals at 8 yrPulse

Systolic BP100100

Vitals at birthPulse

Systolic BP14070

alert & oriented would fall under the category of


C) behaviorA) appearance

appears clean and wel l -groom ed would fa l l under the categoryof


C) behavior C)bronchophony

as k patient to s ay ______________aus cultate luns

Sounds s hould be_________________________________

ninety-ninemuff led & indist inct

if clear this is bronchophony

check accomodation byholding f inger 10 cm f rom pt's nose & askingthem to alternate looking of f to distance & at

f inger. Observe pupillary response

check convergence by moving your f inger toward thebridge of the patient's nose

crackles high pitched similar torubbing hair


egophonyAsk patient to say _____ continuously

You should hear __________________. If youhear _____ this is egophony

"ee"muff led "ee"

"ay"

flat or dull pleural effusion or lobarpneumonia

hyperresonant emphysema orpneumothorax

hypertensive crisis >210 systolic, >120diastolic

maintains eye contact would fall under the category of


C) behavior C) behaviorno s igns o f acute d is tres s would fa l l under the category o f


C) behavior A) appearance

normal healthy lung orbronchitis

normal pulse count for 15 thenx4, if irregular count full minute 60-100 BPM for adult


occipital lymph node islocated at base of skull

postaurical lymph nodeis located behind the ear

preaurical lymph node islocated in front of the ear

respiratory sounds are _____pitched

heart murmurs are _____ pitched high, low

rhonchi snoring, gurgling sound

s peech clear would fall under the category of


C) behavior C) behaviorsubmandibular lymph

node is located under jaw on side

submental lymph nodeis located under jaw midline


superficial lymph node islocated

over and in front of thesternomastoid muscle

supraclavicular lymphnode is located

angle of sternomastoidand clavicle

tactile fremitussay _____________________

palpate using _______ of handYou should/should not feel vibrations

ninety-nineball

should

tonsillar lymph node islocated at angle of jaw

use bell of stethoscopefor ___ pitched sounds low

use diaphragm of stethoscopefor ___ pitched sounds high

weight & height would fall under the category of


C) behaviorB) body structure

wheezes high pitched musical

NLNPhysicalAssessment Flashcards

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