PERRLA - CORRECT ANSWER✅✅pupils equal, round, reactive to light and accommodation
Alert and Oriented - CORRECT ANSWER✅✅measuring of mental function, measured in orientation to
person, place, time, and situation. If a person is oriented to all 4, it is recorded as A&Ox4
MOE X4 - CORRECT ANSWER✅✅movement of extremities, equal motor strength
Brundzski Test - CORRECT ANSWER✅✅Passive Flexion of Neck-Checks for Meningitis
Romberg test - CORRECT ANSWER✅✅Ask the patient to stand about 2 feet in front of you, with his feet
together, toes pointed forward, and his hands at his sides. While you extend your hands so that one is
on either side of the patient, ask him to close his eyes. Watch to see how well he can maintain balance
in that position. A minimum of swaying is normal, but if the patient sways more than a couple of inches,
stop the test and document that he demonstrated difficulty maintaining balance
Babinski reflex - CORRECT ANSWER✅✅Plantar reflex. Test it on the plantar aspect or sole of the foot by
tracing an upside-down J with the handle of the reflex hammer, starting at the patient's heel and moving
up the lateral aspect and then across the ball of the foot.
Adult-Toes Curl Up
Child-Toes Fan Out
Palpation - CORRECT ANSWER✅✅examination of the body using the sense of touch. The pads of the
fingers are used because their concentration of nerve endings makes them highly sensitive to tactile
discrimination
Palpitation is to determine - CORRECT ANSWER✅✅Texture (e.g., of the hair)
Temperature (e.g., of a skin area)
Moisture
Vibration (e.g., of a joint)
, Swelling
Rigidity or spasticity
Crepitation
Location, position, size, consistency, and mobility of organs, lumps, or masses
Distention (e.g., of the urinary bladder)
Amplitude of pulses
The presence of tenderness or pain.
two types of palpitation - CORRECT ANSWER✅✅light and deep
light palpitation - CORRECT ANSWER✅✅(superficial) palpation should always precede deep palpation
because heavy pressure on the fingertips can dull the sense of touch. For light palpation, the nurse
extends the dominant hand's fingers parallel to the skin surface and presses gently while moving the
hand in a circle.
the skin is slightly depressed. If it is necessary to determine the details of a mass, the nurse presses
lightly several times rather than holding the pressure
Deep Palpitation - CORRECT ANSWER✅✅done with one hand or with two hands (bimanually). In deep
bimanual palpation, the nurse extends the dominant hand as for light palpation, then places the finger
pads of the nondominant hand on the dorsal surface of the distal interphalangeal joints of the middle
three fingers of the dominant hand
Percussion - CORRECT ANSWER✅✅the act of striking the body surface to elicit sounds that can be
heard or vibrations that can be felt.
direct percussion - CORRECT ANSWER✅✅the nurse strikes the area to be percussed directly with the
pads of two, three, or four fingers or with the pad of the middle finger. The strikes are rapid, and the
movement is from the wrist
indirect percussion - CORRECT ANSWER✅✅the striking of an object (e.g., a finger) held against the
body area to be examined. In this technique, the middle finger of the nondominant hand, referred to as
the pleximeter, is placed firmly on the patient's skin. Only the distal phalanx and joint of this finger