Nr 304 Health Assessment Ii Final Exam
NR 304 HEALTH ASSESSMENT II FINAL EXAM 1. Cranial nerve 3= oculomotor nerve, responsible for eye movement and pupillary response to light; if it’s functioning properly, expected reaction is pupil constriction in response to light 2. Know pulses: posterior tibial, pedal pulse, femoral, know where they are (there will be a diagram ( HINT KNOW WHERE POSTERIOR TIBIAL PULSE IS) 3. Radial pulse is irregular, assess apical pulse for a full minute!! 4. Objective vs. subjective data 5. Some complications due to immobility: contractures of extremity, crackles in the lungs, pressure ulcers (especially on bony prominences) 6. Voiding small amount of urine less than 100mL frequently (which is 2-3 times an hour) and dribbling of urine are manifestations of urinary retention 7. Auscultate abdomen PRIOR to palpating to prevent altering bowl sounds 8. Self-reporting pain scale, even if patient can’t communicate, they’ll report to you in some way via expressive aphasia (even if they had CVA they’ll let you know if they’re in pain) 9. McBurney’s point for suspected appendicitis, located midway between naval to right iliac crest, press down in lower right quadrant (that’s the area)
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