Week 2 assessment Flashcards

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created 10 months ago by jeana09
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1

Romberg test

Check for balance by having the client stanf with feet together arms at both sides and eye closed and not move for at least 5 seconds

2

Glasgow coma scale

Used as a based line for level on consciousness

3

Assessment technique for the abdomen. Select all that apply

  • Inspect ( look)
  • Auscultation ( hear)
  • purcussion
  • palpation
  • Ask client to urinate before performing the test
  • client will lie supine
  • knees sligthly bent
  • inspect in quadrants starting with the right lower quadrant to right upper left upper left lower.

4

Heart Sound Abnormalities

  • Murmurs: blowing or stwiching sound charateristic of heart desease ( altered flow)
  • Thrills : palpate vibration that can come with murmurs or cardiac malfunctions.
  • Bruits: blowing switching sounds indicative of obstructed perpheral blood flow

5

Ausculatory sites of the heart

  1. Aortic: Right second intercoastal space
  2. Pulmonic: Left second intercoastal space
  3. Erb's point: Left intercoast speace
  4. Tricuspid: Lower left strernal border 4th intercoastal
  5. Mitral : left 5th intercoastal medial to misclavicular line

6

Lordosis

spine curves towards the abdomen

7

Kyphosis

( hunchback) spine curves towars the upper back and it affects the lungs because you're putting pressure towards the abdomen

8

Scoliosis

A lot of teen suffers from it and it is the curvature of the spine sideways

9

Lung sounds that are Abnormal

  • Crackles(rales) : crackling sounds that can go away ( Discontinuous)
  • Whezzing : a high pitch sound caused by airway construction ( continuous)
  • Rhonchi : Sound like snoring ( continious)

10

Physical Assessment techniques (In

order)

  1. Inspect (look)
  2. Palpation ( feeling with hands and fingers)
  3. Percussion ( tapping)
  4. Ausculation ( Listening

11

Nursing process

APPIE

  1. Assess
  2. analyze
  3. plan
  4. implement
  5. evaluate

12

ABC FRAME WORK (PRIORITY). (SELLECT ALL THAT APPLY)

  • AIRWAY
  • BREATHING
  • CIRCULATION

13

Inspection

looking with the naked eye

14

Palpation

feeling with hands and fingers

15

Auscultation

listening to sound of the body

16

percussion

tapping of the body parts