NS 105 - UNIT 4 Class Review Advanced Clinical Assessment and Nursing Practice: Comprehensive Evaluation of Adult Health, Maternal-Fetal Care, Neurocognitive Function, Cardiopulmonary and Peripheral Vascular Systems, Musculoskeletal Integrity, Vital Signs

NS 105 - UNIT 4 Class Review Advanced Clinical Assessment and Nursing Practice: Comprehensive Evaluation of Adult Health, Maternal-Fetal Care, Neurocognitive Function, Cardiopulmonary and Peripheral Vascular Systems, Musculoskeletal Integrity, Vital Signs, Pain Assessment, Diagnostic Reasoning, and Evidence-Based Interventions Exam Questions Verified and Provided with Complete A+ Graded Rationales Latest Updated 2026 0.5-1 inch light palpation bell low pitch noises diaphragm high pitch sounds pupils equal, round, reactive to light and accommodation PERRLA dilated pupils compressed cranial nerve III Bilateral dilated, fixed pupils omnious sign (close to death or brain dead) pinpoint pupils pons damage or drugs head injury brain bleed --act fast (pressing on cranial nerve III) --both will dilate increasing ICP only one dilated pupil may indicate lower tones front of patient when speaking to an elderly patient with a hearing deficit midline assess neck and make sure trachea is: pneumothorax tumors lung removed hemothorax (blood builds up in lung) enlarged thyroid (goiter) ** fluid can build up in lung and push over causing deviation things that cause deviated trachea pass out messing with blood flow to brain do not palpate both carotid arteries at same time causes: bruit auscultate carotid arteries swishing sound blood flow through narrow spot (have them hold their breath and listen) HOB 30-45 Do not want to see jugular vein once upright check for JVD pain 5th vital sign too big? low too small? high what causes abnormal low bp? what causes abnormal high? 96.7 - 100.5 febrile 100.5 hypo pyrexia 96.7 normal temp 60-100 60 bradycardia 60 tachycardia pulse amplitute: 2+ (normal) fluid build up increase in BP bounding pulse indicates? use a doppler-compare both sides (if they don't have a brachial pulse you won't feel the radial) unable to feel pulse 12-20 (Eupnea) bradypnea 12 tachypnea 20 --watch breathing video and typical causes for those Respiratory rate O2 saturation measures amount of oxygen on the hemoglobin --hgb may still have 100% saturation but not getting O2 to tissues Anemic: may show good hgb but not getting to tissues mid 90s to 100 O2 saturation normal: Systolic: 90-120 Diastolic: 60-80 no