WGU HEALTH ASSESSMENT WITH CORRECT QUESTION AND ANSWERS 100%

0/5 - ANSWERS-No muscle movment .1 year - ANSWERS-Pulse 115 SBP 90 .1/5 - ANSWERS-Visible muscle movement but no moment at the joint .2 mon - ANSWERS-smiles recognizes parents .2 year - ANSWERS-Pulse 110 SBP 92 .2/5 - ANSWERS-Movement at the joint but not against gravity .3/5 - ANSWERS-movement against gravity but not against added resist .4 mon - ANSWERS-babbles few words .4/5 - ANSWERS-movement against resistance but less than normal .5 mon - ANSWERS-sits up with support .5/5 - ANSWERS-normal strength .6 mon - ANSWERS-grasps things may hold bottle .6 months - ANSWERS-Pulse 130 SBP 90 .6 year - ANSWERS-Pulse 103 SBP 95 .7 mon - ANSWERS-begins crawling .8 months - ANSWERS-sits without support stranger anxiety .8 year - ANSWERS-Pulse 100 SBP 100 .10 year - ANSWERS-Pulse 95 SPB 105 .12 months - ANSWERS-walks alone .Abdomen contour in a child - ANSWERS-is normally symmetric and slightly rounded .Abdomen contour of in a newborn - ANSWERS-is normally protuberant and soft .Accomodation - ANSWERS-a) Hold your finger about 10cm from the patient's nose. b) Ask them to alternate looking into the distance and at your finger. c) Observe the pupillary response in each eye. .Acoustic - ANSWERS-1. Sensory: Hearing and Equilibrium 2. Initial test: a) Face the patient and hold out your arms with your fingers near each ear. b) Rub your fingers together on one side while moving the fingers noiselessly on the other. c) Ask the patient to tell you when and on which side they hear the rubbing. d) Increase intensity as needed and note any asymmetry. e) Test hearing with normal voice and whispers 3. If abnormal, proceed with the Weber and Rinne tests. .Adbucens - ANSWERS-Motor: lateral eye movement .Adventitious Breath sounds - ANSWERS-Extra breath sounds Crackles Wheezes Rhonchi .anterior fontanel - ANSWERS-diamond shaped closes at 9months - 2 years .aortic area - ANSWERS-listen with diaphragm at the RIGHT 2nd interspace near the sternum .Appearance - ANSWERS-appears to be reported age sexual development appropriate alert and oriented facial features symmetric no signs of acute distress .Assess ears using otoscope - ANSWERS-1. Hold the otoscope upside down with your thumb and fingers so that the ulnar aspect of your hand makes contact with the pt 2. for adults pull the ear upwards and backwards to straighten canal 3. For PEDS pul the ear down and back 4. Use the largest speculum that will fit comfortably .Assess Motor Response - ANSWERS-Observation Involuntary Movements 1. Compare muscle symmetry left to right 2. Proximal vs. distal 3. Atrophy 4. Pay particular attention to the hands, shoulders, and thighs. 5. Gait .Assessment of hernia - ANSWERS-Often needed to be assess standing up .Assessment of Musculoskeletal - ANSWERS-With Musculoskeletal system, Always begin with inspection, palpation and range of motion regardless of the region you are examining except abdomen .Assessment Techniques is as follows - ANSWERS-Inspect-Palpation-Percussion-Auscultation .Atrioventricular AV - ANSWERS-Tricuspid and Mitral S1 "lub" sound .Ausculation - ANSWERS-listening to sounds produced by the body .B/P Norm - ANSWERS-S <130 D <85 .Back of hand - ANSWERS-To assess skin temperature use .Behavior - ANSWERS-maintains eye contact with appropriate expressions comfortable and cooperative speech clear clothing is correct for climate looks cleat and fit appears clean and well groomed .Bell - ANSWERS-picks up low pitched sounds such as heart murmurs .Birth - ANSWERS-Pulse 140 SBP 70 .Birth to 36 months of age - ANSWERS-Body measurements include length or height, weight, and head circumference for children. .Body Structure/mobilty - ANSWERS-weight and height WNL BMI guidelines body parts equal bilaterally stands erect sits comfortably gait is coordinated walk is smooth and well balanced full mobility of joints .borborygmus - ANSWERS-growling .bow legs - ANSWERS-normal to age 3 years; abnormal older. .breath sounds - ANSWERS-are produced by turbulent air flow. They are categorized by the size of the airways that transmit them to the chest wall (and your stethoscope). The general rule is, the larger the airway, the louder and higher pitched the sound. .Bronchovesicular - ANSWERS-and bronchial sounds are heard in between. Inspiration is normally longer than expiration (I > E). .Capillary refill times - ANSWERS-greater than 2-3 seconds suggest PVD arterial blockage heart failure or shock .cerebellum - ANSWERS-gait, coordination, balance, etc. .cerebral - ANSWERS-mental status .Chest circumference - ANSWERS-This is measured at the nipple line in a newborn the head circumference with be about 2 cm larger than the chest circumference AS the child ages the chest circumference becomes larger than the head circumference .clonus - ANSWERS-rapid rhythmic contractions of same muscle its the reflexes seem hyperactive yes for ankle clonus .Clubbing - ANSWERS-a) Normal = 160 degrees b) Curved = 160 degrees or less c) Early clubbing = 180 degrees .Comprehensive history - ANSWERS-which includes chief complaint or reason for the visit a complete review of systems and complete past family and social history should be obtained on the first encounter with a patient regardless of setting and by a RN .Conductive hearing Loss - ANSWERS-Due to mechanical dysfunction of inner or middle ear .Costovertebral Tenderness - ANSWERS-This is often associated with renal disease. 1. Warn the patient what you are about to do. 2. Have the patient sit up on the exam table. 3. Use the heel of your closed fist to strike the patient firmly over the costovertebral angles. 4. Compare left and right sides .Crackles - ANSWERS-These are hight pitched , discontinuous sounds similar to the sound produced by rubbing your hair between your fingers aka as rales .cranial nerves - ANSWERS-sensory motor parasympathetic or mixed .Crisis HTN - ANSWERS-S >210 D >120 .deep cervical chain of lymph nodes - ANSWERS-lies below the sternomastoid and cannot be palpated without getting underneath the muscle inform the pt this procedure will cause discomfort .Deep Palpation - ANSWERS-5-8cm or (2-3") deep is considered .Deep Tendon Reflexes - ANSWERS-1. The patient must be relaxed and positioned properly before starting. 2. Reflex response depends on the force of your stimulus. Use no more force than you need to provoke a definite response. 3. Reflexes can be reinforced by having the patient perform isometric contraction of other muscles (clenched teeth). 4. Exaggerated hyperactive reflexes in a pregnant woman may be related to pre-eclampsia. 5. Reflexes should be graded on a 0 to 4 "plus" scale: .Diaphragmatic Excursion - ANSWERS-Diaphragmatic Excursion 1. Find the level of the diaphragmatic dullness on both sides. 2. Ask the patient to inspire deeply. 3.The level of dullness (diaphragmatic excursion) should go down 3-5 m symmetrically .Diastole - ANSWERS-heart is relaxed .direct auscultation - ANSWERS-sounds are audible without a stethoscope .Ear Abnormal findings - ANSWERS-Erythema-suppurative ottis media, purulent drainage Dull nontransparent gray serous otitis media effusion .Edema, Cyanosis, and Clubbing - ANSWERS-1. Check for the presence of edema (swelling) of the feet and lower legs. 2. Check for the presence of cyanosis (blue color) of the feet or hands. 3. Check for the presence of clubbing of the fingers. .Egophony - ANSWERS-1. Ask the patient to say "ee" continuously. 2. Auscultate several symmetrical areas over each lung 3. You should hear a muffled "ee" sound . If you hear an "ay" sound this referred to as "E->A" or egophony .EOM - ANSWERS-Test Cranial Nerves 3, 4, 6 .Examination Abdomen - ANSWERS-when assessing start in the RLQ over ileocecal valve Watch the pt's face for signs of discomfort during the examination .Extraocular Movement - ANSWERS-1. Check gaze in the six cardinal directions using a cross or "H" pattern. 2. Check convergence by moving your finger toward the bridge of the patient's nose. 3. Pause during upward and lateral gaze to check for nystagmus (involuntary eye movement which differs in each eye). 4. Tests CN 3, 4, and 6 .FABER Test (Hips/sacroiliac joints) - ANSWERS-FABER stands for Flexion, ABduction, and External Rotation of the hip. This test is used to distinguish hip or sacroiliac joint pathology from spine problems. .Facial Droop or Asymmertry - ANSWERS-CN 7 .Facial Test - ANSWERS-1. Mixed: (A) Motor: muscles used for facial expressions, close eye and mouth; (B) Sensory (sense of taste in the front 2/3 of tongue; (C) Parasympathetic: saliva and tear secretion 2. Sense of taste not usually checked unless specific concerns 3. Observe for Any Facial Droop or Asymmetry a) Ask Patient to do the following, note any lag, weakness, or asymmetry: Raise eyebrows b) Close both eyes to resistance c) Smile d) Frown e) Show teeth f) Puff out cheeks 4. Test the Corneal Reflex (See C.N. V above) .Family Health Hx - ANSWERS-Are completed across three generations looking specifically for patterns in genetic issues that negatively impact quality of life .Flatfoot - ANSWERS-pronation of foot in children. Comes from turning of medial side of foot. Normal for 12-30 months; abnormal otherwise. .General Survey - ANSWERS-is an overall review or first impression a nurse has of person's well being. .glossopharyngeal - ANSWERS-Glossopharyngeal 1. Mixed: motor: (A) Motor: pharynx (phonation and swallowing); (B) Sensory: taste on posterior 1/3 of tongue; gag reflex; (C) parasympathetic: parotid gland, carotid reflex. .Grade iii murmur - ANSWERS-moderatley loud easy to hear .Graphesthesia - ANSWERS-a) With the blunt end of a pen or pencil, draw a large number in the patient's palm. b) Ask the patient to identify the number. .hard palate - ANSWERS-located in the anterior part of the mouth it is made of bone and is pale or whitish