What is the assessment technique that you will use to elicit crepitus on the patient who sustained chest
injury?

Palpation

What assessment technique will you use to listen to the heart sounds?

Ascultation

What assessment technique will you use to illicit diaphragmatic excursion?

Percussion

What assessment technique will you use for assessing distended bladder?

 Indirect percussion

Assessment technique that you will use when you're assessing sinus infection?

Direct percussion

instrument used to detect air, blood, fluid, or mass in body cavity

Transilluminator

What part of your hand do you use to determine skin temperature?

Dorsal

What part of your hand do you use for palpation?

Pads of hands

What part of your hand do you use for either direct or indirect percussion?

Middle finger tip

air conduction is 2 times greater than bone conduction

normal Rinne test

Sinuses that are filled with fluid will not transilluminate.

 You will not be able to illicit the red glow
 Make sure the room is dim

difficulty with near vision in elderly patients (farsighted for older)

presbyopia

young adults with difficulty with near vision (farsighted)

hyperopia

young adults with difficulty with far vision (nearsighted)

myopia

When assessing eyes of a patient with right eye retinal detachment, what would you expect?

Diminished vision of the right eye

What is the leading cause of blindness in the US?

Diabetic retinopathy

When testing for integrity of cranial nerve III (oculomotor), what should you advise the patient to do?

Don’t move head. Just move eyes

When testing for Romberg's test, what do you advise the patient?

Put feet together, hands to the side, close eyes, conduct test for 20 seconds, support patient
front and back
o Normal findings: no swaying (less than 2 inch of swaying)
o Abnormal: positive Romberg's test (more than 2 inch of swaying)

What chest is common in pt’s with COPD and in elderly patients

barrel chest

pectus carinatum, forward displacement of the sternum with
depression of adjacent cartilage. No treatment is required.

pigeon chest

congenital deformity when there is depression of the
sternum and adjacent cartilage compressing the heart and lungs. You will hear cardiac murmur on auscultation. In severe cases, patient will need sternum surgery (to reposition the chest, ribs, and sternum)

funnel chest

Low-pitched, grating, rubbing usually due to pleural inflammation

friction rub

Normal for infants to 6 years old:

Common in elderly

barrel chest

Barrel chest is abnormal for patients with

COPD

ntermittent rattling, crackling, popping, orbubbling sound as a result of air reinflating or passingthrough mucus-

crackles

whistling, high pitched musical sounds made by airflowing through narrow airways

wheezes

continuous, low pitched, snoring caused by fluid in larger airways- Sometimes cleared with coughing- CAN BE INDICATIVE OF BRONCHITIS OR COPD

rhonchi

high pitched crowing noise caused by obstruction in upper airway- CAN BE INDICATIVE OF CROUP IN CHILDREN (LIFETHREATENING)

stridor

normal for a skinny person

flat

normal for a very skinny person (anorexic)

scaphoid

: Normal for an obese toddler or early in pregnancy (fat person)

rounded

: Normal for some toddlers, later stages of pregnancy, and
pt’s with ascites

protuberant

Normal belly for a patient with ascites

protuberant

abdominal contour of pregnant women early pregnancy would be rounded late pregnancy 3rd trimester would be

protuberant

What are the main organs that a nurse will assess that are located in the Left upper quadrant of the
abdomen?

stomach and spleen

What are the main organs that are nurse will assess in the right upper quadrant?

liver and gallbladder

When a client has diverticulosis which quadrant of the abdomen will the nurse assess?

LLQ

flat less 1 cm. Brown, blue, red or hypopigmentation

macule/patch

raised less than 1 cm

papule

larger than 1 cm, fluid

vesicle

Ring like

ring worm

painful, vesicles, nerve pathway

herpes

• Irregularly elevated border reddish area, insect bites, hives

wheal

Elevated
• > 1 cm

nodule

Superficial solid elevated
• <1 cm color varies

papule

Circular of free fluid
• < or equal 1 cm

vesicle

SOUND EXPECTED UPON empty ABDOMEN PERCUSSION

tympany

Loud, low pitched, hollow tone
Heard in lungs with no air trapped inside of lungs

resonance

High pitched tone, very soft, and shorter than dullness
Abnormal hearing from bones/muscles

flatness

Abnormally loud, low tone of longer duration than resonance
Heard in lungs with air trapped inside

hyperresonance

impaired peripheral
- increase ocular pressure
- Acute is URGENT!

glaucoma

loss of central vision

macular degeneration

loss of colors
- Results from overexposure to sun and dust resulting in a yellow, thickened, dense lens that
causes blurred vision: part of normal aging

cataracts

Romberg test- balance what CN ?
- Close eyes if swaying=

CN 8

positive

Mcburney point= illum and umbilicus
- Rebound tenderness- put pt. at supine position, pain is felt in opposite side

appendicitis

tonic pupil, slugglish pupillary response

Adie's pupil

non reactive to light. occurs with CNS disorders like tumor or syphilis

Argyll Robertson pupils

Fixed and constricted pupils

Miosis

Unequal pupillary size

anisocoria

fixed and dilated

mydriasis

Changes in the skin in pregnancy :

________ increases

Development of ___ and _____ are common

_____ and ____ become hyperactive

Worsening _____ in the first trimester

Hair may fall out during months

skin pigmentation

melasma and linea negra

Oil and sweat glands

acne

1-5

UTI symptoms

- Increased urinary urgency

- Dysuria

- suprapubic or lower back pain

- hematuria

- cloudy, foul-smelling urine.

BPH symptoms (3)

urinary _____

difficulty starting ______

______ voiding, especially at

-urinary retention

-difficulty starting a stream

-overflow voiding especially at night.

Breast changes in pregnancy

• Enlargement of breast tissue for lactation
• Pigmentation changes
• Colostrum leakage prior to childbirth

breast pain that goes away naturally once you get your period, but returns during your next menstrual cycle.

cyclic

reast pain may be continuous or it may come and go. It can affect women before and after the menopause.

non cyclic breast pain

A stretching or tearing of the capsule or ligament of a joint due to forced movement beyond the joint's normal range

joint sprain

partial or complete break in the continuity of the bone from trauama

fracture

risk factors of osteoperosis

Highest risk: females, caucasian and asian, post-menopause- Hereditary- Limit alcohol, smoking, and caffeine

S/S of an MI (subjective)

pain in chest

SOB

nausea and anxiety

S/S of an MI (objective)

diaphoresis

pallor

vomiting and changes in the EKG