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How do you assess muscle strength? - ANSWER-Ask the
person to flex and hold as you apply opposing force. Muscle
strength should be equal bilaterally and fully resist against
your opposing force. Grading scale 5-0. 5- full rom with full
resistance. 3- full rom with gravity. 1- slight contraction.
What is a stupor LOC? - ANSWER-Partial or almost complete
unconsciousness. Spontaneous consciousness, has
appropriate motor response.
What does a chronic ear infection look like? - ANSWER-Ear
Perforation, hole in
the tympanic
membrane
carotene-rich foods consumed in large amounts cause –
ANSWER-Carotenemia, Yellow-Orange skin tones in light
skinned people. There is no yellowing of the eyes.
Where do you palpate on abdomen? - ANSWER-Palpate always
last! Four quadrants, palpate- liver, spleen, intestines,
,appendix. Should not feel any pain, there should be no lumps
bulges or masses present!
How do you assess EOM? - ANSWER-Cardinal positions of
gaze, Ask pt to fallow pen light without moving their head.
Move the penlight to the six cardinal positions returning to the
mid point after each movement. This tests CN 3,4,6 and EOM
What is the apical impulse? - ANSWER-pulse felt at point of
maximal impulse
cyanosis - ANSWER-a bluish discoloration of the skin
resulting from poor
circulation or inadequate oxygenation of
the blood.
Where do you hear the tricuspid valve? - ANSWER-4th
intercostal space near
the sternum on the pts left side (your
right side)
Where do you percuss the heart? - ANSWER-@ the anterior
axillary line and continue toward the sternum along the 5th
intercostal space. the sound changes from resonance to
dullness over the left border of the heart, normally at the
midclavicular line. The right border of the heart is usually
aligned with the sternum and can't be percussed.
, How do you assess JVD? - ANSWER--Place pt in
supine positon
-Elevate head
45degrees
-Turn head to one
side
-Look for
pulsations
-If greater than 3cm distention, positive jugular
vein distention
How do you assess grade 4 systolic murmur? - ANSWER-It
would be during the
first heart sound, then determine quality: blowing, musical
harsh or rumbling.
Then the pitch High, Low? Then location, where is the sound the
loudest? grade
on a 6 level grading
scale.
What is the S1 sound? - ANSWER-"lub" and AV valves
closing. tricuspid and
mitral
valves.
What is the S2 sound? - ANSWER-"Dub", closure of semilunar
valves, aortic