Med-surg. ANCC certification
Mc burney's point - ANSPoint in RLQ abd of appendix. Tenderness indicates appendicitis
Murphy's sign - ANSPlace fingers under rt coastal margin and instruct to take deep breath.
Increased tenderness with sudden stop during inhalation is a positive murphy's sign
Obturator muscle,
psoas sign,
Rovsing's sign - ANSAll assessment used to r/o appendicitis
Homan's sign - ANSOut dated and not recommended to use for assessment for DVT
Jar sign(markle sign) - ANSPain from a jarring movement to indicate peritonitis with
appendicitis. Stand on toes and drop to heals or increaded pain with walking or running
Beck's triad - ANSAcute cardiac tamponade- pericardial effusion
1. Disended neck vein's
2. Distant heart sounds
3. Hypotention
Treatment- pericardiocentesis
Charcot's triad for MS - ANS1. Nystagmas- repetitive uncontrolled movements of the eyes
2. Intention tremor- tremor that worsens as approaches end of intended movement
3. Scanning or staccato speech- broken speech and each syllable pronounced separately
Charcot's triad for ascending cholangitis - ANSInf. of bile duct caused by bacteria ascending
from junction with duodenum
1.Jaundice
2. Fever, usually with rigors
3. RUQ ABD pain
Cushing's triad - ANSSigns of increased ICP
1. HTN- widened pulse pressure
2. Bradycardia
3. Irregular respirations- cheyne- stokes( slow, fast, slow period of apnea then slow,fast,slow
Kaussmaul breathing - ANSDeep and labored. Presents in severe metabolic acidosis- DKA
and kidney failure
Bergman's triad - ANSSigns of fat embolism
1. Mental status changes
2. Petechiae-late sign
3. Dyspnea
, Brudzinski sign - ANSSign of meningitis- supine flex neck will cause involuntary flexion of
hips and knees
Kernig's sign - ANSSign of meningitis- lift flexed knee and slowly extend will cause back pain
if positive
Chvostek's sign
Trousseau' sign - ANSNerve hyperexcitability (tetany) seen with hypocalemia
Abnormal reaction to stimulation of facial nerve
Inflate bp cuff to greater than systolic and hand and wrist with involuntarly curl inward
Levine sign - ANSis positive when a patient is holding a clenched fist over his chest to
describe dull, pressing chest pain consistent with the discomfort of angina pectoris.
A patient is diagnosed with a lateral wall ST segment elevation myocardial infarction
(STEMI). What do you expect the EKG to show?
a. ST elevation in leads V1 -V6
b. ST elevation in leads I, aVL, V5, V6
c. ST elevation in leads II, III, aVF
d. ST elevation in leads V7, V8, V9 - ANSB: Choice B would show a lateral wall MI.
Choice A would show an anterior MI.
Choice C would show an inferior wall MI.
Choice D would show a posterior wall MI.
Epididymitis - ANScommonly caused by E.coli in elderly males and/or those who are not
sexually active and have normal immune function. In sexually active males with a history of
unprotected sex, the causative organisms are likely gonorrhea and/or chlamydia. Cases of
epididymitis caused by Staph aureus are rare. Epididymitis caused by cytomegalovirus
(CMV) is incredibly rare unless the patient is immunocompromised.
Triple H therapy for
Subarachnoid Hemorrhage- induced
Vasospasm - ANSNimodipine or Nimotop is a calcium channel blocker which causes
vasodilation of the blood vessels. is hypervolemia, hypertension, and hemodilution. These
three factors will maintain the patency of the vessels, making it difficult for them to
vasoconstrict. Vasospasm left unchecked can cause stroke, neurological compromise, and
death.
Iatrogenic - ANSAdverse effects caused by dx procedure or treatment
Confussion assessment method(cam) - ANSDx delirium
1 Acute onset
2 Inattention
3 Disorganized thinking
4 ALOC
Mc burney's point - ANSPoint in RLQ abd of appendix. Tenderness indicates appendicitis
Murphy's sign - ANSPlace fingers under rt coastal margin and instruct to take deep breath.
Increased tenderness with sudden stop during inhalation is a positive murphy's sign
Obturator muscle,
psoas sign,
Rovsing's sign - ANSAll assessment used to r/o appendicitis
Homan's sign - ANSOut dated and not recommended to use for assessment for DVT
Jar sign(markle sign) - ANSPain from a jarring movement to indicate peritonitis with
appendicitis. Stand on toes and drop to heals or increaded pain with walking or running
Beck's triad - ANSAcute cardiac tamponade- pericardial effusion
1. Disended neck vein's
2. Distant heart sounds
3. Hypotention
Treatment- pericardiocentesis
Charcot's triad for MS - ANS1. Nystagmas- repetitive uncontrolled movements of the eyes
2. Intention tremor- tremor that worsens as approaches end of intended movement
3. Scanning or staccato speech- broken speech and each syllable pronounced separately
Charcot's triad for ascending cholangitis - ANSInf. of bile duct caused by bacteria ascending
from junction with duodenum
1.Jaundice
2. Fever, usually with rigors
3. RUQ ABD pain
Cushing's triad - ANSSigns of increased ICP
1. HTN- widened pulse pressure
2. Bradycardia
3. Irregular respirations- cheyne- stokes( slow, fast, slow period of apnea then slow,fast,slow
Kaussmaul breathing - ANSDeep and labored. Presents in severe metabolic acidosis- DKA
and kidney failure
Bergman's triad - ANSSigns of fat embolism
1. Mental status changes
2. Petechiae-late sign
3. Dyspnea
, Brudzinski sign - ANSSign of meningitis- supine flex neck will cause involuntary flexion of
hips and knees
Kernig's sign - ANSSign of meningitis- lift flexed knee and slowly extend will cause back pain
if positive
Chvostek's sign
Trousseau' sign - ANSNerve hyperexcitability (tetany) seen with hypocalemia
Abnormal reaction to stimulation of facial nerve
Inflate bp cuff to greater than systolic and hand and wrist with involuntarly curl inward
Levine sign - ANSis positive when a patient is holding a clenched fist over his chest to
describe dull, pressing chest pain consistent with the discomfort of angina pectoris.
A patient is diagnosed with a lateral wall ST segment elevation myocardial infarction
(STEMI). What do you expect the EKG to show?
a. ST elevation in leads V1 -V6
b. ST elevation in leads I, aVL, V5, V6
c. ST elevation in leads II, III, aVF
d. ST elevation in leads V7, V8, V9 - ANSB: Choice B would show a lateral wall MI.
Choice A would show an anterior MI.
Choice C would show an inferior wall MI.
Choice D would show a posterior wall MI.
Epididymitis - ANScommonly caused by E.coli in elderly males and/or those who are not
sexually active and have normal immune function. In sexually active males with a history of
unprotected sex, the causative organisms are likely gonorrhea and/or chlamydia. Cases of
epididymitis caused by Staph aureus are rare. Epididymitis caused by cytomegalovirus
(CMV) is incredibly rare unless the patient is immunocompromised.
Triple H therapy for
Subarachnoid Hemorrhage- induced
Vasospasm - ANSNimodipine or Nimotop is a calcium channel blocker which causes
vasodilation of the blood vessels. is hypervolemia, hypertension, and hemodilution. These
three factors will maintain the patency of the vessels, making it difficult for them to
vasoconstrict. Vasospasm left unchecked can cause stroke, neurological compromise, and
death.
Iatrogenic - ANSAdverse effects caused by dx procedure or treatment
Confussion assessment method(cam) - ANSDx delirium
1 Acute onset
2 Inattention
3 Disorganized thinking
4 ALOC
