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N190 Finals Focused ReviewDifferent types of assessment techniques-Inspection-Auscultation-Percussion-PalpationWhich technique should the nurse do initially among the 4 techniques?-InspectionWhen a patient sustained chest injury, which technique will the nurse use to elicit crepitus?-PalpationWhat assessment technique is used when listening to heart sounds?-AuscultationWhat technique is used to elicit diaphragmatic excursion?-PercussionWhat technique will the nurse use when assessing full/distended bladder?-Indirect percussion What technique will be used by the nurse to assess for sinus infection?-direct percussion with the index finger++++++++++++++++++++++++++++++++Identify the common equipment used in the clinical area:What instrument is used to assess the degree of joint flexion & extension?-GoniometerWhat is the used of the doppler?-To assess non-palpable pulsesWhat is used to assess fungal infection on the skin?-Wood lampWhat is the use of the skinfold caliper?-Used to assess subcutaneous thicknessWhat instrument is used to detect solid, fluid or masses in body cavities-Transilluminator How are pulses graded?-0 – 4+o0 = no pulseo1+ = weak & thready
o2+ = normalo3+ = brisko4+ = boundingWhere can you palpate the popliteal artery/pulses?-Behind the kneesWhere can you palpate the femoral pulses? -Inguinal areaWhat part of the hands is used to assess skin temperature?-Dorsal part of the hand++++++++++++++++++++++++++++++++Different types of lesions:What lesion has concentric circles of color& has a dot in the center?-Target lesionWhat is the other name for target lesion?-“bullseye” lesionWhat is annular lesion?-It is a one-circle lesionWhat are discrete lesions?-Lesions that are separatedWhat are confluent lesions?-Lesions that run togetherWhat are linear lesions?-Lesions that form a lineWhat do you call lesions that are together?-Grouped lesionsThese are lesions caused by insect bites/hives, & have reddened irregular border-WhealWhat is the difference between a vesicle & a bulla?-Bullae is bigger than vesicleWhat is the size of a bullae?-More than 0.5 cmWhat is the size of vesicle?-Less than 0.5 cm
How would you describe a vesicle & bullae?-round/oval shape-palpable mass -thin translucent wall-filled with fluidHow do we grade edema?-1+ to 4+o1+ = 2mmo2+ = 4mmo3+ = 6mmo4+ = 8mm++++++++++++++++++++++++++++++++*Review cranial nerves - know the corresponding tests being done for each CN- what are the normal & abnormal findings for each CN12 Cranial NervesCN I – Olfactory Nerve = sense of smellCN II – Optic Nerve =Snellen test (distant vision) & Rosenbaum test (close proximity vision)CN III – Oculomotor Nerve CN IV – Trochlear Nerve PERRLA & 6 CARDINAL FIELD OF GAZESCN VI – Abducens NerveCN V – Trigeminal Nerve = clenching of the teeth, opening & closing the mouth, protrude jaw (front) them back, move L & RCN VII – Facial Nerve = movement of the face, smile, frown, puff the cheeks, raise eyelids/eyebrows up & downCN VIII - Vestibulocochlear Nerve= whisper test and Romberg’s testCN IX – Glossopharyngeal Nerve = gag reflex & swallowingCN X– Vagus Nerve = swallowing and phonationCN XI – Accessory Nerve = shoulders