NURS190 FINAL REVISED VERSION EXAM 2025

The different types of assessment techniques? - - Inspection Palpation Percussion Auscultation Which technique should the nurse use initially for each specific assessment? - inspection Assessment technique to illicit a diaphragmatic excursion? - -percussion Technique used to listen to heart sounds? - -auscultation Technique used to listen to crepitus who sustained a chest injury? - -palpation What is the technique used to assess distended bladder? - -direct percussion What is the technique used to assess sinus infection? - -direct percussion What is the technique used for percussion of the lungs? - -indirect percussion Identify the most common equipment used in the clinical area Goniometer Doppler Wood lamp Skin fold caliper Transilluminator Stabio Stethoscope Ophthalmoscope - -goniometer: measure the degree of joint extension and flexion Doppler: asses non palpable pulses Wood lamp: presence of fungal infection of skin Skinfold caliper: measure thickness of subcutaneous tissue Trans illuminator: use to detect blood, solid or fluid or mass in body cavities Stabio meter: height of pt. NURS 190 NURS 190 Stethoscope, penlight Ophthalmoscope: red reflex Grading for pulses - -0 : absent 1+: weak thready 2+: normal 3+: brisk 4+: bounding Location of pulses - -popliteal : behind the knees Femoral: inguinal area What part of your hand do you use to assess skin temperature? - -dorsal part of hand What part of your hand do you use to use percussion? - -tip of middle finger Identify different types of lesions Annular Target Dicerete Confluent Linear Grouped - -annular: one circle Target: concentric circles (more than one circle of color) Discrete: separated Confluent: runs together Linear: form a line Grouped: together Wheal lesion - -lesion caused by insect bite or hive Redden irregular border Vesicle - -elevated lesion round or oval filled with clear fluid Smaller vesicle vs bulla Bulla lesion - -larger vesicle More than 0.5 cm NURS 190 NURS 190 How do you grade edema - -0: no edema 1+: 2mm 2+: 4mm 3+: 6mm 4+: 8mm Cranial nerves - - i: olfactory : 2 senses Ii: optic : snellen chart Iii: oculomotor : perrla and cardinal field of gaze Iv: trochlear: perrla and cardinal field of gaze V: trigeminal : tmj Vi: abducens :perrla and cardinal field of gaze Vii: facial : smile, frown, puff cheeks, raise eyebrows Viii: vestibulocochlear : whisper test and rombergs test Ix: glossopharyngeal: hold trachea, swallow, tongue depressor X: vagus: swallow and repeat phrase Xi: accessory : move shoulders up and down with and without resistance Xii: hypoglossal: stick tongue out, side to side, up and down 10 lymph nodes - - 1. Periauricular: in front of ear 2. Postauricular: back of ear 3. Occipital: behind head 4. Sub mental: under front chin 5. Submandibular: underside of jaw 6. Retropharyngeal or tonsillar: under upper part of jaw 7: superficial cervical chain: front of sternocleidmastoid 8. Deep cervical chain: deep in the sternocleidomastoid muscle 9. Posterior cervical chain: behind sternocleidomastoid 10. Supraclavicular: above clavicle Lymph nodes in adults versus children - -adults are non palpable if palpable there is a sign of infection NURS 190 NURS 190 NURS 190 Children are palpable but still need to see provider Vascular lesions: venous lake - -soft lesion on lips or neck Elevated Dark blue Compressible Vascular lesions: port wine stain - -flat irregular shaped Pale red to deep purple red Color deepens in response to exertion, emotion or when patient cries, elevated temperature Hemangioma - -bright red raised lesions Non blanched with pressure Present at birth or a few months and goes away at age of 10 Spiderangioma - -bright red with tiny radiating blood vessels Ranging from pinpoint to 2cm Blanches with pressure Abdominal palpation - -light : use finger pads, 1/2 - 1 cm, safest Moderate: use finger pads, 1-2 cm, determine depth size shape and consistency and mobility of orders, tenderness, and pulsations Deep: use palm of hand up to metacarpal joint, 2-4cm, caution, use to assess organs deep within the body (liver, kidney) Assess head of patient and you notice sores that have been there for months, what you suspect? - -skin malignancy or skin cancer Lyme disease what would you ask patient? - -have you been hiking or camping lately? Due to the bite of the tick What do you do when your patient refuses to continue with the physical examination? - document what was done and what was refused Nystagmus - -jerky movement of eyes during the 6 cardinal field of gaze Weber test - -activate the thinne of the tuning fork and put it on the midline of skull Negative: pt hear vibration equal lateralization on the right and left Positive: lateralization goes to defected ear NURS 190 Rhinne test - -activate thinne of tuning fork and place it at the mastoid then midline of skull Normal: ac 2x greater than bc Transillumination - -red glow: sinuses are normal Absent of red glow: sinuses are filled with fluid Red reflex - -illicit with opthalmoscope Distance to eyelash Presbyopia - -elderly patient has difficulty with near vision (farsightedness) Hyperopia - -adult difficulty with near vision (farsightedness) Myopia - -adult difficulty with far vision (nearsightedness) In an optometry which patient would require immediate atte