NURS 2121 Clinical Lab > Untitled Deck > Flashcards

Untitled Deck Flashcards

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1
Q

What is the standard assessment sequence?

A

Inspection, Palpation, Percussion, Auscultation (I-P-P-A)

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2
Q

What is the correct assessment sequence for the abdomen?

A

Inspection, Auscultation, Percussion, Palpation (I-A-P-P)

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3
Q

Which assessment technique should you always start with?

A

Inspection

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4
Q

Why is auscultation done before palpation/percussion in the abdomen?

A

Palpation/percussion can change bowel sounds, so you listen first for accuracy

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5
Q

What does inspection focus on during a physical assessment?

A

Symmetry, color, posture, distress, lesions, edema, gait, breathing pattern

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6
Q

Which part of the hand is best to assess skin temperature?

A

Dorsal hand

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7
Q

Which part of the hand is best to assess texture, size, shape, and tenderness?

A

Fingertips

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8
Q

Which part of the hand is best to feel vibration, thrills, and heaves?

A

Palm or base of fingers

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9
Q

What is palpation used for?

A

Assess texture, temperature, tenderness, masses, and vibration

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10
Q

What is percussion used for?

A

To assess density of underlying tissues (air, fluid, solid)

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11
Q

What percussion sound is expected over normal lungs?

A

Resonance

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12
Q

What does hyperresonance suggest?

A

Too much air (e.g., emphysema)

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13
Q

What percussion sound is expected over the stomach/intestines?

A

Tympany

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14
Q

What does dullness suggest on percussion?

A

Solid tissue, fluid, or a mass (e.g., liver, consolidation)

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15
Q

What percussion sound is expected over bone or dense muscle?

A

Flatness

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16
Q

What is auscultation used for?

A

Listening to internal sounds (heart, lungs, bowel, bruits)

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17
Q

When do you use the diaphragm side of the stethoscope?

A

High-pitched sounds (breath, bowel, normal heart sounds S1/S2)

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18
Q

When do you use the bell side of the stethoscope?

A

Low-pitched sounds (murmurs, bruits, S3/S4)

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19
Q

What happens if you press the bell too hard?

A

It acts like a diaphragm and can miss low-pitched sounds

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20
Q

What is a thrill?

A

A palpable vibration felt on the skin from turbulent blood flow

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21
Q

How do you assess a thrill?

A

Palpation

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22
Q

What is a bruit?

A

A whooshing sound heard over an artery from turbulent blood flow

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23
Q

How do you assess a bruit?

A

Auscultation (usually with the bell)

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24
Q

What is the best first type of question when starting an interview?

A

Open-ended question

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25
Give an example of an open-ended question.
“What brings you in today?”
26
Why are open-ended questions important?
They build rapport and encourage the patient to share their story
27
When are closed-ended questions most useful?
To clarify and confirm specific details
28
What are key “internal factors” in communication?
Empathy, caring, active listening, nonjudgment, appropriate silence
29
What is empathy (in healthcare communication)?
Acknowledging and understanding the patient’s feelings without judgment
30
What does OLD CARTS stand for?
Onset, Location, Duration, Characteristics, Aggravating factors, Relieving factors, Timing, Severity
31
In OLD CARTS, what does “Onset” mean?
When the symptom started
32
In OLD CARTS, what does “Location” mean?
Where the symptom is felt
33
In OLD CARTS, what does “Duration” mean?
How long it lasts and whether it is constant or intermittent
34
In OLD CARTS, what does “Characteristics” mean?
What it feels like (sharp, dull, burning, throbbing, etc.)
35
In OLD CARTS, what does “Aggravating” mean?
What makes it worse
36
In OLD CARTS, what does “Relieving” mean?
What makes it better
37
In OLD CARTS, what does “Timing” mean?
Pattern or when it occurs (time of day, triggers, frequency)
38
In OLD CARTS, what does “Severity” mean?
How bad it is, usually rated 0–10
39
What does cultural competence mean in nursing?
Providing care that respects the patient’s values, beliefs, and preferences
40
What is a culturally competent approach when you’re unsure of a patient’s preferences?
Ask the patient directly and adapt care based on their answers
41
What is the single most effective way to prevent infection transmission?
Hand hygiene
42
When must you use soap and water instead of alcohol-based sanitizer?
C. difficile, norovirus, or when hands are visibly soiled
43
Why is C. difficile high-risk for spread in healthcare settings?
It forms spores that survive on surfaces and spread easily by contact
44
What type of precautions are used for C. difficile?
Contact precautions
45
What PPE is required for contact precautions?
Gown and gloves upon room entry
46
What type of precautions are used for influenza?
Droplet precautions
47
What PPE is required for droplet precautions?
Surgical mask (add other PPE if splash risk)
48
What type of precautions are used for tuberculosis (TB)?
Airborne precautions
49
What PPE is required for airborne precautions?
N95/respirator and negative-pressure room
50
What are the three levels of prevention?
Primary, Secondary, Tertiary
51
What is primary prevention?
Prevent disease before it happens (e.g., vaccines, education)
52
What is secondary prevention?
Early detection/screening (e.g., BP checks, Pap tests)
53
What is tertiary prevention?
Reduce complications after diagnosis (e.g., rehab, chronic disease management)
54
What is included in the general survey?
Overall appearance, distress, posture, hygiene, gait, mood/affect, skin color, obvious edema, orientation
55
When does the general survey begin?
As soon as you first see the patient
56
Common causes of tachycardia include what?
Pain, fever, dehydration, anxiety, hypoxia, anemia, hyperthyroidism, stimulants
57
Common causes of bradycardia include what?
Athletic conditioning, beta blockers, hypothyroidism, conduction problems
58
Common causes of elevated blood pressure include what?
Pain, anxiety, stimulants, fluid overload, chronic hypertension
59
Common causes of low blood pressure include what?
Dehydration, blood loss, sepsis, medications
60
What BP error occurs with a cuff that is too small?
Falsely high blood pressure
61
What BP error occurs with a cuff that is too large?
Falsely low blood pressure
62
How does arm position affect BP readings?
Arm below heart level reads higher; above heart level reads lower
63
Why should the patient rest before taking BP?
Activity can falsely elevate the reading
64
Why should the patient not talk during BP measurement?
Talking can raise BP and reduce accuracy
65
What does “bias reduction” mean in assessment?
Using neutral, respectful language and focusing on objective findings
66
What is the goal of bias reduction during patient assessment?
Provide fair, accurate care without assumptions or judgment
67
Where is the aortic valve listening area?
2nd intercostal space, right sternal border
68
Where is the pulmonic valve listening area?
2nd intercostal space, left sternal border
69
Where is Erb’s point?
3rd intercostal space, left sternal border
70
Where is the tricuspid valve listening area?
4th–5th intercostal space, left lower sternal border
71
Where is the mitral (apex) listening area?
5th intercostal space, midclavicular line
72
What does S1 represent?
Closure of the mitral and tricuspid valves (start of systole)
73
What does S2 represent?
Closure of the aortic and pulmonic valves (end of systole)
74
What does S3 often suggest in older adults?
Possible fluid overload/heart failure (context matters)
75
What does S4 often suggest?
Stiff ventricle (often pathologic)
76
What is JVD?
Jugular venous distension (neck vein bulging from increased venous pressure)
77
What does JVD often indicate?
Increased right-sided heart pressure/volume overload
78
Best position to assess JVD?
Head of bed at about 30–45 degrees
79
What is claudication?
Leg pain with walking/exertion relieved by rest
80
Claudication suggests what condition?
Peripheral arterial disease (PAD)
81
How do you grade pulses in general?
0 absent, 1+ weak, 2+ normal, 3+ bounding
82
What are common peripheral pulses you assess?
Radial, brachial, dorsalis pedis, posterior tibial
83
What is pitting edema?
Swelling that leaves an indentation when pressed
84
What does 1+ pitting edema usually look like?
Slight pit with quick rebound
85
What does 4+ pitting edema usually look like?
Very deep pit with very prolonged rebound
86
Common signs of heart failure include what?
Edema, JVD, dyspnea/orthopnea, fatigue, weight gain, crackles (esp. left-sided)
87
What does “A&O” mean?
Alert and oriented
88
What does the Romberg test assess?
Balance and proprioception
89
What is a positive Romberg sign?
Increased swaying or falling with eyes closed
90
What does a positive Romberg suggest?
Sensory/proprioception problem (not cerebellar)
91
What does the cerebellum mainly control?
Coordination and balance
92
Examples of cerebellar tests include what?
Finger-to-nose, rapid alternating movements, heel-to-shin, tandem gait
93
Cranial nerve I controls what?
Smell
94
Cranial nerve II controls what?
Vision
95
Cranial nerves III, IV, and VI control what?
Extraocular movements (EOMs) and pupil responses (III)
96
How do you test cranial nerve V?
Facial sensation and jaw clench (mastication)
97
How do you test cranial nerve VII?
Facial movements (smile, frown, raise eyebrows, puff cheeks)
98
How do you test cranial nerve VIII?
Hearing (e.g., whisper test)
99
How do you test cranial nerves IX and X?
Swallowing, palate rise, voice quality (“ah”)
100
How do you test cranial nerve XI?
Shoulder shrug and head turn against resistance
101
How do you test cranial nerve XII?
Stick out tongue and move it side to side
102
What is the purpose of sinus assessment?
Detect tenderness/inflammation of frontal and maxillary sinuses
103
How do you assess the TMJ?
Palpate while the patient opens/closes the mouth for clicking, pain, or limited movement
104
What’s a common “best first step” priority framework?
ABCs (airway, breathing, circulation)
105
If a vital sign seems wrong or unsafe, what is a common best next step?
Reassess/confirm and then escalate based on severity
106
If infection risk is suspected before touching the patient, what should you do first?
Perform hand hygiene and apply appropriate precautions/PPE
NURS 2121 Clinical Lab
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