NU 210 Final Exam - Key Points
Abbreviated Head to Toe Assessment- Specifically for Eyes & Ears Exam, Neuro Exam, or whatever- know main
parts of abbreviated health assessment (PERRLA?) - Correct Answer Tool in Lab Bag used with this (usually carry in
pocket & turn it on & off)- PENLIGHT
PERRLA: Pupils are *P*resent, *E*qual, *R*ound, *R*eactive to *L*ight, *A*ccomodating
Abbreviated Head to Toe- Directly about GI system in Post Op Patient- What would you do in terms of IPPA? -
Correct Answer Perform Inspection, AUSCULTATION, Percussion, Palpation
- Don't want to alter bowel motility (listen first, then move to actual touch)
- Bowel sounds could be hypoactive or even absent after surgery and one should listen for 5 minutes to document
absent bowel sounds
Assessment of Patient's Mental Health Status
(Select All That Apply- *4* RIGHT out of 5 Options) - Correct Answer What are you going to assess?'
●*LOC*- (Lethargy, Obtunded, Stupor, Coma), Glascow Coma Scale (AVPU), SNOT, Posturing
●*Successful Aging*- SLUMS
●*Dementia*
●*Alzheimer's*
●*Delirium*- PINCHME, Assess LOC, Memory, Speech, Cognitive Functions, SLUMS, CAM
●*Depression*- Depression Questionnaire, Sleep, Appetite, Cognitive, Mood, Activity
●*Suicide*- SADPERSONS, Availability to Lethal Means
● *Alcohol* - SBIRT, AUDIT tool, CAGE self-assessment
Comprehensive Assessment vs. General Survey (Which of 4 answers is in General Survey?) - Correct Answer
*General Survey*:
o Confirm Patient's Name, DOB, Age
o Telephone Number
o Height/Weight
o State of Health
o Nutritional Status
o Personal Hygiene
o Signs of distress
o Facial Expression & Mood
o LOC x3 (what about x4?)- Person, Place, Time ( & Event)
- Can you please tell me who you are? where you are? what time of day it is? what month and year it is?
(Given 4 assessments & we have to determine which is General Survey)
-------------------------------------------------------
Answer: Vital signs (includes pain), height, weight, BMI, overall appearance, and LOC (questions)
Questions to ask: What is your name, address, telephone number (cell and email address), How old are you?, Can
you tell me where you are?, Can you tell me what year it is?, Can you tell me what today's date is?
Assessing level of consciousness and baseline information
Ex) eye assessment, skin/hair, head/neck, but what is in the general survey
Book ex) Ht: 5 ft 1 in; Wt: 175 lb; Radial pulse: 68; Resp: 18; B/P: R arm—132/76, L arm—128/72; Temp: 98.6. Client
alert and cooperative. Sitting comfortably on table with arms at sides. Dress is neat and clean. Walks steadily, with
posture erect.Thin and frail in appearance. Skin pale, warm, and dry. No acute physical distress noted. Alert and
oriented to person, place, time, and events.
It begins when the nurse first meets the client.
Comprehensive Assessment: Alzheimer's Patient- How would you accommodate when doing a patient's subjective
interview/health history - Correct Answer In General: Take it slow, allow time for questions, Limit distractions ( turn
, down TV) & other environmental factors, Distractors from answering questions? Can they hear you? Can they see
you? Etc
What Stage of Alzheimer's are they in? Pre-clinical, Mild Cog Impairment, or Dementia of Alzheimer's (How severe is
case?)
Prepare for symptom manifestations= loss of recent memory, depression, anxiety, personality changes, unpredictable
quirks or behaviors, confusion, aggression, agitation, suspicion, wandering, trouble sleeping, inability to recognize
family members, & probs w/ language, calculation, & abstract thinking. Inability to manage a budget & gradually
worsening ability to remember new info
Assessment: Can a spouse, child, or caregiver be present for exam to confirm stated data? (interview separately to
look for similarities/ differences/ refer to patient's medical chart to confirm previous procedures, etc. ), keep to 3rd or
4th grade learning level when providing education. See what level of cognitive impairment pt has using tools like
CAM, SLUMS, etc.
Comprehensive Head to Toe- Sequence of Comprehensive Head to Toe- what's first? What's last?
Think about what you did in PE Final (what did you do first? Last?) - Correct Answer 1) First, review patient's chart
before entering, hand hygiene, introduce self to the patient, review what will happen today (explain procedure), and
confirm name & DOB before proceeding.
2) Start with *General Survey* -> take vital signs -> Move on to Physical Head to Toe Exam
*Head & Neck* (Size, symmetry, deformity, scalp, hair, face, palpate temporal arteries & TMJ for crepitus) -> *Eyes*
(Inspect for position, lesions, color, redness, use ophthalmoscope to test red reflex) -> *Ears* (Inspect for position,
drainage, color & use otoscope to view tympanic membrane) -> *Nose* (Inspect for color, drainage, lesions & patency
of airflow. Also inspect using transillumination & palpate sinuses) -> *Mouth* (Inspect lips & inside mouth, inspect
uvula & tonsils & palpate tongue w/ gauze) -> *Neck* (Inspect, test ROM, lymph nodes, palpate trachea, & thyroid
gland -> *Upper Extremities* (Inspect, ROM, Cap Refill, Epitrochlear Lymph Nodes, Palpate pulses, test reflexes, &
sensation) -> *Thorax* (IPPA, chest expansion) -> *Lungs* (Inspect, note respiration quality, auscultate, skin turgor) -
> *Breasts* (Explain process & importance of SBEs, tail of spence, types of motion, abnormal findings ,etc) -> *Heart*
(Inspect & palpate apical, auscultate heart sounds, assess for JVD) -> *Abdomen* (Inspect, Auscultate all 4
quadrants, percuss, & palpate) -> *Lower Extremities* (Inspect, ROM, Cap Refill, sensations, Heel to Shin, test
reflexes, palpate pulses) -> *Spine* (Inspect curvature, gait, test tandem walk, hopping on one leg, Romberg, Finger
to Nose) -> *Genital/ Rectal* (gather equipment, explain procedure & purpose, request permission) -> Cranial Nerves
(or integrate into assessment parts)
3) Before leaving, hand hygiene, ask patient if they have any questions or concerns, Thank them for their time &
patience.
Comprehensive Health Assessment- Patient's Permission w/ Assessment
What principle of obtaining a client's permission is important when obtaining a pt's health assessment? - Correct
Answer After introducing self to client, nurse explains purpose of interview, discusses types of questions that will be
asked, explains reason for taking notes, & assures client that confidential info will remain confidential. It is important
to understand HIPAA. Make sure they are physically & emotionally comfortable. Make sure to fully explain purpose,
what is involved, etc. then ask patient if it would be okay to proceed and if they have further questions before
proceeding. Assure them that assessment can stop at any time if they feel uncomfortable.
Must receive patient's VERBAL PERMISSION in order to proceed
Cranial Nerve Assessment - Correct Answer - *CN 1) Olfactory*- have pt occlude 1 nostril, then see if they can
identify familiar smell (do for both). Also check for patency of airflow with each
- *CN 2) Optic*- Check PERRLA (pupils, equal, round, reactive to light, accommodating), check pupillary reflex using
penlight (both eyes should constrict when light shined into one), Test visual fields using Wiggle Test or hand over
eye, check for accommodating using pen to nose test. Both should constrict as pen gets closer; should also move in
simultaneously
.
- *CN Oculomotor (3), Trochlear (4), & Abducen(6)*- Test 6 Cardinal Fields for eye movement
- *CN 5) Trigeminal*- use a sharp and soft edged object ot test sensation of person's face on cheek, jawline, &
forehead. Have them distinguish "sharp" or "dull".
- *CN 7) Facial*- checks for facial movement/ expression- have pt smile, frown, show teeth, puff cheeks, raise
eyebrows, & tightly close eyes."
Abbreviated Head to Toe Assessment- Specifically for Eyes & Ears Exam, Neuro Exam, or whatever- know main
parts of abbreviated health assessment (PERRLA?) - Correct Answer Tool in Lab Bag used with this (usually carry in
pocket & turn it on & off)- PENLIGHT
PERRLA: Pupils are *P*resent, *E*qual, *R*ound, *R*eactive to *L*ight, *A*ccomodating
Abbreviated Head to Toe- Directly about GI system in Post Op Patient- What would you do in terms of IPPA? -
Correct Answer Perform Inspection, AUSCULTATION, Percussion, Palpation
- Don't want to alter bowel motility (listen first, then move to actual touch)
- Bowel sounds could be hypoactive or even absent after surgery and one should listen for 5 minutes to document
absent bowel sounds
Assessment of Patient's Mental Health Status
(Select All That Apply- *4* RIGHT out of 5 Options) - Correct Answer What are you going to assess?'
●*LOC*- (Lethargy, Obtunded, Stupor, Coma), Glascow Coma Scale (AVPU), SNOT, Posturing
●*Successful Aging*- SLUMS
●*Dementia*
●*Alzheimer's*
●*Delirium*- PINCHME, Assess LOC, Memory, Speech, Cognitive Functions, SLUMS, CAM
●*Depression*- Depression Questionnaire, Sleep, Appetite, Cognitive, Mood, Activity
●*Suicide*- SADPERSONS, Availability to Lethal Means
● *Alcohol* - SBIRT, AUDIT tool, CAGE self-assessment
Comprehensive Assessment vs. General Survey (Which of 4 answers is in General Survey?) - Correct Answer
*General Survey*:
o Confirm Patient's Name, DOB, Age
o Telephone Number
o Height/Weight
o State of Health
o Nutritional Status
o Personal Hygiene
o Signs of distress
o Facial Expression & Mood
o LOC x3 (what about x4?)- Person, Place, Time ( & Event)
- Can you please tell me who you are? where you are? what time of day it is? what month and year it is?
(Given 4 assessments & we have to determine which is General Survey)
-------------------------------------------------------
Answer: Vital signs (includes pain), height, weight, BMI, overall appearance, and LOC (questions)
Questions to ask: What is your name, address, telephone number (cell and email address), How old are you?, Can
you tell me where you are?, Can you tell me what year it is?, Can you tell me what today's date is?
Assessing level of consciousness and baseline information
Ex) eye assessment, skin/hair, head/neck, but what is in the general survey
Book ex) Ht: 5 ft 1 in; Wt: 175 lb; Radial pulse: 68; Resp: 18; B/P: R arm—132/76, L arm—128/72; Temp: 98.6. Client
alert and cooperative. Sitting comfortably on table with arms at sides. Dress is neat and clean. Walks steadily, with
posture erect.Thin and frail in appearance. Skin pale, warm, and dry. No acute physical distress noted. Alert and
oriented to person, place, time, and events.
It begins when the nurse first meets the client.
Comprehensive Assessment: Alzheimer's Patient- How would you accommodate when doing a patient's subjective
interview/health history - Correct Answer In General: Take it slow, allow time for questions, Limit distractions ( turn
, down TV) & other environmental factors, Distractors from answering questions? Can they hear you? Can they see
you? Etc
What Stage of Alzheimer's are they in? Pre-clinical, Mild Cog Impairment, or Dementia of Alzheimer's (How severe is
case?)
Prepare for symptom manifestations= loss of recent memory, depression, anxiety, personality changes, unpredictable
quirks or behaviors, confusion, aggression, agitation, suspicion, wandering, trouble sleeping, inability to recognize
family members, & probs w/ language, calculation, & abstract thinking. Inability to manage a budget & gradually
worsening ability to remember new info
Assessment: Can a spouse, child, or caregiver be present for exam to confirm stated data? (interview separately to
look for similarities/ differences/ refer to patient's medical chart to confirm previous procedures, etc. ), keep to 3rd or
4th grade learning level when providing education. See what level of cognitive impairment pt has using tools like
CAM, SLUMS, etc.
Comprehensive Head to Toe- Sequence of Comprehensive Head to Toe- what's first? What's last?
Think about what you did in PE Final (what did you do first? Last?) - Correct Answer 1) First, review patient's chart
before entering, hand hygiene, introduce self to the patient, review what will happen today (explain procedure), and
confirm name & DOB before proceeding.
2) Start with *General Survey* -> take vital signs -> Move on to Physical Head to Toe Exam
*Head & Neck* (Size, symmetry, deformity, scalp, hair, face, palpate temporal arteries & TMJ for crepitus) -> *Eyes*
(Inspect for position, lesions, color, redness, use ophthalmoscope to test red reflex) -> *Ears* (Inspect for position,
drainage, color & use otoscope to view tympanic membrane) -> *Nose* (Inspect for color, drainage, lesions & patency
of airflow. Also inspect using transillumination & palpate sinuses) -> *Mouth* (Inspect lips & inside mouth, inspect
uvula & tonsils & palpate tongue w/ gauze) -> *Neck* (Inspect, test ROM, lymph nodes, palpate trachea, & thyroid
gland -> *Upper Extremities* (Inspect, ROM, Cap Refill, Epitrochlear Lymph Nodes, Palpate pulses, test reflexes, &
sensation) -> *Thorax* (IPPA, chest expansion) -> *Lungs* (Inspect, note respiration quality, auscultate, skin turgor) -
> *Breasts* (Explain process & importance of SBEs, tail of spence, types of motion, abnormal findings ,etc) -> *Heart*
(Inspect & palpate apical, auscultate heart sounds, assess for JVD) -> *Abdomen* (Inspect, Auscultate all 4
quadrants, percuss, & palpate) -> *Lower Extremities* (Inspect, ROM, Cap Refill, sensations, Heel to Shin, test
reflexes, palpate pulses) -> *Spine* (Inspect curvature, gait, test tandem walk, hopping on one leg, Romberg, Finger
to Nose) -> *Genital/ Rectal* (gather equipment, explain procedure & purpose, request permission) -> Cranial Nerves
(or integrate into assessment parts)
3) Before leaving, hand hygiene, ask patient if they have any questions or concerns, Thank them for their time &
patience.
Comprehensive Health Assessment- Patient's Permission w/ Assessment
What principle of obtaining a client's permission is important when obtaining a pt's health assessment? - Correct
Answer After introducing self to client, nurse explains purpose of interview, discusses types of questions that will be
asked, explains reason for taking notes, & assures client that confidential info will remain confidential. It is important
to understand HIPAA. Make sure they are physically & emotionally comfortable. Make sure to fully explain purpose,
what is involved, etc. then ask patient if it would be okay to proceed and if they have further questions before
proceeding. Assure them that assessment can stop at any time if they feel uncomfortable.
Must receive patient's VERBAL PERMISSION in order to proceed
Cranial Nerve Assessment - Correct Answer - *CN 1) Olfactory*- have pt occlude 1 nostril, then see if they can
identify familiar smell (do for both). Also check for patency of airflow with each
- *CN 2) Optic*- Check PERRLA (pupils, equal, round, reactive to light, accommodating), check pupillary reflex using
penlight (both eyes should constrict when light shined into one), Test visual fields using Wiggle Test or hand over
eye, check for accommodating using pen to nose test. Both should constrict as pen gets closer; should also move in
simultaneously
.
- *CN Oculomotor (3), Trochlear (4), & Abducen(6)*- Test 6 Cardinal Fields for eye movement
- *CN 5) Trigeminal*- use a sharp and soft edged object ot test sensation of person's face on cheek, jawline, &
forehead. Have them distinguish "sharp" or "dull".
- *CN 7) Facial*- checks for facial movement/ expression- have pt smile, frown, show teeth, puff cheeks, raise
eyebrows, & tightly close eyes."
