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72 Cards in this Set
- Front
- Back
Subjective data
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said by client
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Objective data
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observed by nurse
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Inspection
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look at color, shape, symmetry, position
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Use _______ to assess skin temperature
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back of hand (dorsal)
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Use ___________ to assess texture, moisture, areas of tenderness
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fingertips
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Sounds are audible without stethoscope
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direct auscultation
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Uses stethoscope
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indirect auscultation
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Sound characteristics of auscultation
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frequency, pitch intensity, duration, quality
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use bell of stethoscope for ___ pitched sounds
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low
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use diaphragm of stethoscope for ___ pitched sounds
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high
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respiratory sounds are _____ pitched
heart murmurs are _____ pitched |
high, low
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alert & oriented would fall under the category of
A) appearance B) body structure C) behavior |
A) appearance
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no signs of acute distress would fall under the category of
A) appearance B) body structure C) behavior |
A) appearance
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weight & height would fall under the category of
A) appearance B) body structure C) behavior |
B) body structure
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Gait would fall under the category of
A) appearance B) body structure C) behavior |
B) body structure
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maintains eye contact would fall under the category of
A) appearance B) body structure C) behavior |
C) behavior
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appears clean and well-groomed would fall under the category of
A) appearance B) body structure C) behavior |
C)
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speech clear would fall under the category of
A) appearance B) body structure C) behavior |
C) behavior
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Integumentary system - inspect skin for
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color, moisture, hair pattern, rashes, lesions, edema, pallor
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Palpate skin for
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temperature, turgor, lesions, edema
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Height - measure in recumbant position for ages _____.
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under 2 (up to 3 if unable to stand)
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Head circumference is measured until age ______.
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36 months
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Normal temperatures
Oral - |
98.6F/37C
+1 for rectal & aural, -1 for axillary |
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Normal respirations
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14-20 breaths/minute
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normal pulse count for 15 then x4, if irregular count full minute
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60-100 BPM for adult
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Blood pressure should be taken in both arms when?
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on first encounter, use higher number arm for recording
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Vitals at birth
Pulse Systolic BP |
140
70 |
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Vitals at 6mo
Pulse Systolic BP |
130
90 |
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Vitals at 1 yr
Pulse Systolic BP |
115
90 |
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Vitals at 2 yr
Pulse Systolic BP |
110
92 |
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Vitals at 6 yr
Pulse Systolic BP |
103
95 |
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Vitals at 8 yr
Pulse Systolic BP |
100
100 |
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Vitals at 10 yr
Pulse Systolic BP |
95
105 |
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Hold otoscope with thumb & fingers so that __________ aspect of your hand makes contact with patient
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ulnar
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Frontal sinuses are located _________________
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below eyebrows
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Maxillary sinuses are located _____________________
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below zygomatic arch
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Pull ear ______ and _________ for adult
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up and back
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Pull ear ______ and _________ for child
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down and back
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Palpate lymph nodes with _________
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pads of your index and middle finger
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preaurical lymph node is located
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in front of the ear
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postaurical lymph node is located
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behind the ear
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occipital lymph node is located
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at base of skull
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tonsillar lymph node is located
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at angle of jaw
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submandibular lymph node is located
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under jaw on side
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submental lymph node is located
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under jaw midline
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superficial lymph node is located
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over and in front of the sternomastoid muscle
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supraclavicular lymph node is located
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angle of sternomastoid and clavicle
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The __________________________ of lymph nodes lies below the sternomastoid muscle and cannot be palpated without _____________________________________.
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deep cervical chain
getting underneath the muscle |
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To assess temporomandibular joint place the ________________________________ directly in front of the ________________ of each _____________.
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tips of your index fingers
tragus ear |
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To test visual acuity the patient should/should not wear glasses
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should
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Position patient at 20 feet for ______________ chart
or at 14 feet for ___________________ pocket card. |
Snellen
Rosenbaum |
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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 _____________________________________ |
Visual fields by confrontation
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Corneal reflection should be centered ____________________ when you shine a light directly in front of the patient
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centered over the pupils
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Extraocular movement tests which of the cranial nerves
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3, 4, and 6
oculomotor, trochlear, abducens |
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Check extraocular movements by
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six cardinal directions using H pattern
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check convergence by
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moving your finger toward the bridge of the patient's nose
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check accomodation by
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holding finger 10 cm from pt's nose & asking them to alternate looking off to distance & at finger. Observe pupillary response
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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.
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left
right |
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Look through the opthalmoscope and shine the light into the patient's eye from about _____________ away. You should see the retina as a ________________.
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2 feet
red reflex |
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Adjust the opthalmoscope to a ____________________________ and set the diopter dial to __________.
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plain white circle
0 |
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To percuss the chest
hyperextend the ____________ finger of one hand and place the _____________________________ firmly against the patient's chest. |
middle
distal interphalangeal joint |
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Use the end or the pad of the opposite middle finger to flick with when percussing the chest.
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end
|
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flat or dull
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pleural effusion or lobar pneumonia
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normal
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healthy lung or bronchitis
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hyperresonant
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emphysema or pneumothorax
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crackles
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high pitched similar to rubbing hair
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wheezes
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high pitched musical
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rhonchi
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snoring, gurgling sound
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tactile fremitus
say _____________________ palpate using _______ of hand You should/should not feel vibrations |
ninety-nine
ball should |
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bronchophony
ask patient to say ______________ auscultate luns Sounds should be _________________________________ |
ninety-nine
muffled & indistinct if clear this is bronchophony |
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egophony
Ask patient to say _____ continuously You should hear __________________. If you hear _____ this is egophony |
"ee"
muffled "ee" "ay" |
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hypertensive crisis
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>210 systolic, >120 diastolic
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