NSE 103 Scenarios Questions with Correct
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Terms in this set (20)
- HH + intro
- Permission to touch
- LMK if you have pain or discomfort
- Flexion: hands straight up over head
Assess for ROM of - Extension: hands behind back straight
shoulders. Provide 3 - Internal rotation: hands behind back
findings. - External rotation: hands behind head
- Abduction: hands side and up
- Adduction: one arm at a time, move arm across
body
- "no pain, no crepitation, full ROM"
- HH + intro
Assess your partner's
- Permission to touch
fingernails for
- palms facing down
shape/contour (note 1
- "nails are rounded and curved"
findings), consistency
- palpate nail "nails are smooth with uniform thickness
(note 2 findings), and the
and firm nail base"
profile sign (note findings).
- nail side profile "angle of nail base is 160 degrees"
, - HH + intro
- Permission to touch
Assess your partner's skin
- client put arm up palm facing down
turgor and assess
- pinch up skin on forearm "good skin mobility, easily
moisture, texture, and
return to place, no tenting"
thickness on arms. report 1
- sleeve over shoulder, palpate down arm with
finding for each.
fingertips of both hands "no moisture, texture is
smooth and even, no thickness of skin felt"
- HH + intro
- Permission to touch
- lay flat on back, I'm going to lift up your shirt
- clean stethoscope
Auscultate and name all
- palpate down 2nd intercostal space, right sternal
four valves with the
border where aortic valve is. Left sternal border is
diaphragm and provide 2
where pulmonic valve is located. Palpate to 5th
findings
intercostal space left sternal border, tricuspid valve.
Midclavicular line, mitral valve
- Clear s1 and s2, no split sounds, no murmur, can hear
s1 louder at apex, s2 louder at base
- HH + intro
- Permission to touch
- clean stethoscope
- lay flat, pillow behind head
- drape
Auscultate bowel sounds
- use diaphragm, bottom right abdomen, top right,
and provide 3 findings
top left, bottom left
- tshirt down
- in all 4 quadrants "note normal irregular frequency
of bowel sounds, 5 - 30 per minute, high pitched,
cascading and gurgling"
Answers | Latest Update
Save
Terms in this set (20)
- HH + intro
- Permission to touch
- LMK if you have pain or discomfort
- Flexion: hands straight up over head
Assess for ROM of - Extension: hands behind back straight
shoulders. Provide 3 - Internal rotation: hands behind back
findings. - External rotation: hands behind head
- Abduction: hands side and up
- Adduction: one arm at a time, move arm across
body
- "no pain, no crepitation, full ROM"
- HH + intro
Assess your partner's
- Permission to touch
fingernails for
- palms facing down
shape/contour (note 1
- "nails are rounded and curved"
findings), consistency
- palpate nail "nails are smooth with uniform thickness
(note 2 findings), and the
and firm nail base"
profile sign (note findings).
- nail side profile "angle of nail base is 160 degrees"
, - HH + intro
- Permission to touch
Assess your partner's skin
- client put arm up palm facing down
turgor and assess
- pinch up skin on forearm "good skin mobility, easily
moisture, texture, and
return to place, no tenting"
thickness on arms. report 1
- sleeve over shoulder, palpate down arm with
finding for each.
fingertips of both hands "no moisture, texture is
smooth and even, no thickness of skin felt"
- HH + intro
- Permission to touch
- lay flat on back, I'm going to lift up your shirt
- clean stethoscope
Auscultate and name all
- palpate down 2nd intercostal space, right sternal
four valves with the
border where aortic valve is. Left sternal border is
diaphragm and provide 2
where pulmonic valve is located. Palpate to 5th
findings
intercostal space left sternal border, tricuspid valve.
Midclavicular line, mitral valve
- Clear s1 and s2, no split sounds, no murmur, can hear
s1 louder at apex, s2 louder at base
- HH + intro
- Permission to touch
- clean stethoscope
- lay flat, pillow behind head
- drape
Auscultate bowel sounds
- use diaphragm, bottom right abdomen, top right,
and provide 3 findings
top left, bottom left
- tshirt down
- in all 4 quadrants "note normal irregular frequency
of bowel sounds, 5 - 30 per minute, high pitched,
cascading and gurgling"
