Nln Physical Assessment

Front 1

Subjective data

Back 1

said by client

Front 2

Objective data

Back 2

observed by nurse

Front 3

Inspection

Back 3

look at color, shape, symmetry, position

Front 4

Use _______ to assess skin temperature

Back 4

back of hand (dorsal)

Front 5

Use ___________ to assess texture, moisture, areas of tenderness

Back 5

fingertips

Front 6

Sounds are audible without stethoscope

Back 6

direct auscultation

Front 7

Uses stethoscope

Back 7

indirect auscultation

Front 8

Sound characteristics of auscultation

Back 8

frequency, pitch intensity, duration, quality

Front 9

use bell of stethoscope for ___ pitched sounds

Back 9

low

Front 10

use diaphragm of stethoscope for ___ pitched sounds

Back 10

high

Front 11

respiratory sounds are _____ pitched
heart murmurs are _____ pitched

Back 11

high, low

Front 12

alert & oriented would fall under the category of

A) appearance
B) body structure
C) behavior

Back 12

A) appearance

Front 13

no signs of acute distress would fall under the category of

A) appearance
B) body structure
C) behavior

Back 13

A) appearance

Front 14

weight & height would fall under the category of

A) appearance
B) body structure
C) behavior

Back 14

B) body structure

Front 15

Gait would fall under the category of

A) appearance
B) body structure
C) behavior

Back 15

B) body structure

Front 16

maintains eye contact would fall under the category of

A) appearance
B) body structure
C) behavior

Back 16

C) behavior

Front 17

appears clean and well-groomed would fall under the category of

A) appearance
B) body structure
C) behavior

Back 17

C)

Front 18

speech clear would fall under the category of

A) appearance
B) body structure
C) behavior

Back 18

C) behavior

Front 19

Integumentary system - inspect skin for

Back 19

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

Front 20

Palpate skin for

Back 20

temperature, turgor, lesions, edema

Front 21

Height - measure in recumbant position for ages _____.

Back 21

under 2 (up to 3 if unable to stand)

Front 22

Head circumference is measured until age ______.

Back 22

36 months

Front 23

Normal temperatures
Oral -

Back 23

98.6F/37C

+1 for rectal & aural, -1 for axillary

Front 24

Normal respirations

Back 24

14-20 breaths/minute

Front 25

normal pulse count for 15 then x4, if irregular count full minute

Back 25

60-100 BPM for adult

Front 26

Blood pressure should be taken in both arms when?

Back 26

on first encounter, use higher number arm for recording

Front 27

Vitals at birth
Pulse
Systolic BP

Back 27

140
70

Front 28

Vitals at 6mo
Pulse
Systolic BP

Back 28

130
90

Front 29

Vitals at 1 yr
Pulse
Systolic BP

Back 29

115
90

Front 30

Vitals at 2 yr
Pulse
Systolic BP

Back 30

110
92

Front 31

Vitals at 6 yr
Pulse
Systolic BP

Back 31

103
95

Front 32

Vitals at 8 yr
Pulse
Systolic BP

Back 32

100
100

Front 33

Vitals at 10 yr
Pulse
Systolic BP

Back 33

95
105

Front 34

Hold otoscope with thumb & fingers so that __________ aspect of your hand makes contact with patient

Back 34

ulnar

Front 35

Frontal sinuses are located _________________

Back 35

below eyebrows

Front 36

Maxillary sinuses are located _____________________

Back 36

below zygomatic arch

Front 37

Pull ear ______ and _________ for adult

Back 37

up and back

Front 38

Pull ear ______ and _________ for child

Back 38

down and back

Front 39

Palpate lymph nodes with _________

Back 39

pads of your index and middle finger

Front 40

preaurical lymph node is located

Back 40

in front of the ear

Front 41

postaurical lymph node is located

Back 41

behind the ear

Front 42

occipital lymph node is located

Back 42

at base of skull

Front 43

tonsillar lymph node is located

Back 43

at angle of jaw

Front 44

submandibular lymph node is located

Back 44

under jaw on side

Front 45

submental lymph node is located

Back 45

under jaw midline

Front 46

superficial lymph node is located

Back 46

over and in front of the sternomastoid muscle

Front 47

supraclavicular lymph node is located

Back 47

angle of sternomastoid and clavicle

Front 48

The __________________________ of lymph nodes lies below the sternomastoid muscle and cannot be palpated without _____________________________________.

Back 48

deep cervical chain
getting underneath the muscle

Front 49

To assess temporomandibular joint place the ________________________________ directly in front of the ________________ of each _____________.

Back 49

tips of your index fingers
tragus
ear

Front 50

To test visual acuity the patient should/should not wear glasses

Back 50

should

Front 51

Position patient at 20 feet for ______________ chart
or at 14 feet for ___________________ pocket card.

Back 51

Snellen
Rosenbaum

Front 52

Stand 2 feet in front of patient & have them look into your eyes
Hold your hands to the side half way between you and patient
Wiggle fingers on one hand
Ask patient to indicate which side they see your fingers move.
This is screens _____________________________________

Back 52

Visual fields by confrontation

Front 53

Corneal reflection should be centered ____________________ when you shine a light directly in front of the patient

Back 53

centered over the pupils

Front 54

Extraocular movement tests which of the cranial nerves

Back 54

3, 4, and 6
oculomotor, trochlear, abducens

Front 55

Check extraocular movements by

Back 55

six cardinal directions using H pattern

Front 56

check convergence by

Back 56

moving your finger toward the bridge of the patient's nose

Front 57

check accomodation by

Back 57

holding finger 10 cm from pt's nose & asking them to alternate looking off to distance & at finger. Observe pupillary response

Front 58

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

Back 58

left
right

Front 59

Look through the opthalmoscope and shine the light into the patient's eye from about _____________ away. You should see the retina as a ________________.

Back 59

2 feet
red reflex

Front 60

Adjust the opthalmoscope to a ____________________________ and set the diopter dial to __________.

Back 60

plain white circle
0

Front 61

To percuss the chest
hyperextend the ____________ finger of one hand and place the _____________________________ firmly against the patient's chest.

Back 61

middle
distal interphalangeal joint

Front 62

Use the end or the pad of the opposite middle finger to flick with when percussing the chest.

Back 62

end

Front 63

flat or dull

Back 63

pleural effusion or lobar pneumonia

Front 64

normal

Back 64

healthy lung or bronchitis

Front 65

hyperresonant

Back 65

emphysema or pneumothorax

Front 66

crackles

Back 66

high pitched similar to rubbing hair

Front 67

wheezes

Back 67

high pitched musical

Front 68

rhonchi

Back 68

snoring, gurgling sound

Front 69

tactile fremitus
say _____________________
palpate using _______ of hand
You should/should not feel vibrations

Back 69

ninety-nine
ball
should

Front 70

bronchophony
ask patient to say ______________
auscultate luns
Sounds should be _________________________________

Back 70

ninety-nine
muffled & indistinct
if clear this is bronchophony

Front 71

egophony
Ask patient to say _____ continuously
You should hear __________________. If you hear _____ this is egophony

Back 71

"ee"
muffled "ee"
"ay"

Front 72

hypertensive crisis

Back 72

>210 systolic, >120 diastolic