NLN Physical Assessment

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

plain white circle 0

on first encounter, use higher number arm for recording

Blood pressure should be taken in both arms when?

Check extraocular movements by

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

six cardinal directions using H pattern centered over the pupils

Extraocular movement tests which of the cranial nerves

3, 4, and 6 oculomotor, trochlear, abducens

Frontal sinuses are located _________________

Gait would fall under the category of A) appearance B) body s tructure C) behavior

below eyebrows
B) body structure

Head circumference is measured until age ______.

36 months

NLN Physical Assessment

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Height - measure in recumbant position for ages _____.

under 2 (up to 3 if unable to stand)

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

ulnar
look at color, shape, symmetry, position
color, moisture, hair pattern, rashes, lesions, edema, pallor

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

2 feet red reflex

Maxillary sinuses are located _____________________

below zygomatic arch

Normal respirations
Normal temperatures Oral -

14-20 breaths/minute
98.6F/37C +1 for rectal & aural, -1 for axillary

NLN Physical Assessment

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Objective data
Palpate lymph nodes with _________

observed by nurse
pads of your index and middle finger temperature, turgor, lesions, edema Snellen Rosenbaum

Palpate skin for

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

Pull ear ______ and _________ for adult Pull ear ______ and _________ for child Sound characteristics of auscultation Sounds are audible without stethoscope

up and back
down and back
frequency, pitch intensity, duration, quality

direct auscultation

NLN Physical Assessment

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S ta n d 2 fe e t i n fr o n t o f p a ti e n t & h a ve th e m l o o k i n to yo u r e ye s Ho l d yo u r h a n d s to th e s i d e h a l f wa y b e twe e n yo u a n d p a ti e n t Wi g g l e fi n g e r s o n o n e h a n d As k p a ti e n t to i n d i ca te wh i ch s i d e th e y s e e yo u r fi n g e r s m o ve . Th i s i s s cr e e n s _____________________________________

Visual fields by confrontation

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

said by client
deep cervical chain getting underneath the muscle

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

tips of your index fingers tragus ear

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

middle distal interphalangeal joint

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

should
back of hand (dorsal)

Use _______ to assess skin temperature

Use ___________ to assess texture, moisture, areas of tenderness

fingertips

NLN Physical Assessment

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

end
left right

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.

Uses stethoscope
Vitals at 1 yr Pulse Systolic BP

indirect auscultation
115 90 95 105 110 92 103 95 130 90

Vitals at 10 yr Pulse Systolic BP

Vitals at 2 yr Pulse Systolic BP

Vitals at 6 yr Pulse Systolic BP

Vitals at 6mo Pulse Systolic BP

NLN Physical Assessment

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Vitals at 8 yr Pulse Systolic BP

100 100 140 70

Vitals at birth Pulse Systolic BP

alert & oriented would fall under the category of A) appearance B) body s tructure C) behavior

A) appearance

a p p e a r s cl e a n a n d we l l -g r o o m e d wo u l d fa l l u n d e r th e ca te g o r y of A) a p p e a r a n ce B ) b o d y s tr u ctu r e C) b e h a vi o r

C)
ninety-nine muffled & indistinct if clear this is bronchophony

bronchophony as k patient to s ay ______________ aus cultate luns Sounds s hould be _________________________________

check accomodation by

holding f inger 10 cm f rom pt's nose & asking them to alternate looking of f to distance & at f inger. Observe pupillary response

check convergence by

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

crackles

high pitched similar to rubbing hair

NLN Physical Assessment

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

"ee" muffled "ee" "ay"

flat or dull
hyperresonant
hypertensive crisis
maintains eye contact would fall under the category of A) appearance B) body s tructure C) behavior

pleural effusion or lobar pneumonia emphysema or pneumothorax >210 systolic, >120 diastolic

C) behavior
A) appearance
healthy lung or bronchitis

n o s i g n s o f a cu te d i s tr e s s wo u l d fa l l u n d e r th e ca te g o r y o f A) a p p e a r a n ce B ) b o d y s tr u ctu r e C) b e h a vi o r

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

60-100 BPM for adult

NLN Physical Assessment

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occipital lymph node is located postaurical lymph node is located preaurical lymph node is located
respiratory sounds are _____ pitched heart murmurs are _____ pitched

at base of skull

behind the ear

in front of the ear

high, low
snoring, gurgling sound

rhonchi
s peech clear would fall under the category of A) appearance B) body s tructure C) behavior

C) behavior
under jaw on side under jaw midline

submandibular lymph node is located submental lymph node is located

NLN Physical Assessment

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superficial lymph node is located supraclavicular lymph node is located

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

over and in front of the sternomastoid muscle angle of sternomastoid and clavicle
ninety-nine ball should

tonsillar lymph node is located use bell of stethoscope for ___ pitched sounds
use diaphragm of stethoscope for ___ pitched sounds

at angle of jaw

low high
B) body structure
high pitched musical

weight & height would fall under the category of A) appearance B) body s tructure C) behavior

wheezes