Nurs 202. Final Exam Review
What are the vital signs? - answer Temperature
Pulse
Respirations
(TPR)
Blood Pressure
*Pain is considered the 5th vital sign
Normal Temperature Range - answer96.7F to 100.5F
(35.9C to 38C)
Normal Pulse Rate - answer60-100 BPM
Bradycardia- less than 60
Tachycardia- greater than 100
Pulse Characteristics - answerPulse rate (60-100bpm)
Beats per minute
Pulse rhythm
Regularity versus irregularity (Dysrhythmia)
Pulse amplitude (strength)
0 Absent, unable to palpate
+1 Diminished, weaker than expected
+2 Brisk, expected (normal)
+3 Bounding
Pulse equality
-Left versus right
Pulse Deficit - answerApical pulse higher than radial
Normal Respirations - answer12-20 breaths per minute
Respirations Characteristics - answerRate (12-20)
Rhythm
Amplitude (depth)
Pulse Oximeter - answerSaturation of O2 on hemoglobin (Hgb)
,Percent of hemoglobin fully saturated with O2
Normal adult 93-100%
Anything below 90 is a concern
Normal BP - answer120/80
Systolic BP - answer1st Korotkoff sound, top number
Ventricular contraction
Pressure on the arterial wall, normal is 120
Diastolic BP - answer2nd Korotkoff sound, bottom number
Ventricular relaxation
Pressure at rest or relaxing on arterial walls, normal is 80
Causes of Erroneous BP Readings - answerBladder too wide or too large- false low
Bladder too small- false high
Vital Signs Special Considerations - answerCan't take BP on side of someone who had
mastectomy
Food and drink affect temperature- wait to take temp after breakfast
Weighing 400 lbs. there's a special cuff
Purpose of the Health Assessment - answerWhy they're here
Want to learn the baseline data for all future assessments of this patient
What are the assessment techniques - answerInspection (1)
Palpation (2)
Percussion (3)
Auscultation (4)
Skin Color Assessment - answerJaundice- yellow
Cyanosis- blue
Erythema- red
Pallor- pale
Vitiligo- whitish patches on the skin
, Tanned or brown
Patients with Skin Cancer: ABCDE - answerA - Asymmetry
B - Boarder irregular
C - Color variegated
D - Diameter > 6 mm
E - Enlarging
Moles, irregular pattern, bumpy, change in color
Equipment for Assessment of the head and neck - answerpen light
tongue depressor
gloves
Assessment of the Eyes - answerSnellen chart measures visual acuity, pupil size
PERRLA (Pupils Equal Round Reactive to Light & Accomodation)
Accommodation- start with the object far then move it far looking for the pupils to dilate
when object is closer,
Convergence when the eyes cross or go in on the object
Extraocular movements- cardinal directions, Both eyes are coordinated, parallel, making
the H
Visual Acuity
Snellen Chart
20/20 vision (20/30 or 20/50
Peripheral Vision
Equal on both side
Normal Lung sounds - answerBronchial Sounds
Bronchovesicular Sounds
Vesicular Sounds
Bronchial Sounds - answerHeard over lungs and trachea
High-pitched, harsh "blowing" sounds
Bronchovesicular - answerHeard over mainstem bronchus
Heard posteriorly between scapula and anteriorly lateral to sternum
What are the vital signs? - answer Temperature
Pulse
Respirations
(TPR)
Blood Pressure
*Pain is considered the 5th vital sign
Normal Temperature Range - answer96.7F to 100.5F
(35.9C to 38C)
Normal Pulse Rate - answer60-100 BPM
Bradycardia- less than 60
Tachycardia- greater than 100
Pulse Characteristics - answerPulse rate (60-100bpm)
Beats per minute
Pulse rhythm
Regularity versus irregularity (Dysrhythmia)
Pulse amplitude (strength)
0 Absent, unable to palpate
+1 Diminished, weaker than expected
+2 Brisk, expected (normal)
+3 Bounding
Pulse equality
-Left versus right
Pulse Deficit - answerApical pulse higher than radial
Normal Respirations - answer12-20 breaths per minute
Respirations Characteristics - answerRate (12-20)
Rhythm
Amplitude (depth)
Pulse Oximeter - answerSaturation of O2 on hemoglobin (Hgb)
,Percent of hemoglobin fully saturated with O2
Normal adult 93-100%
Anything below 90 is a concern
Normal BP - answer120/80
Systolic BP - answer1st Korotkoff sound, top number
Ventricular contraction
Pressure on the arterial wall, normal is 120
Diastolic BP - answer2nd Korotkoff sound, bottom number
Ventricular relaxation
Pressure at rest or relaxing on arterial walls, normal is 80
Causes of Erroneous BP Readings - answerBladder too wide or too large- false low
Bladder too small- false high
Vital Signs Special Considerations - answerCan't take BP on side of someone who had
mastectomy
Food and drink affect temperature- wait to take temp after breakfast
Weighing 400 lbs. there's a special cuff
Purpose of the Health Assessment - answerWhy they're here
Want to learn the baseline data for all future assessments of this patient
What are the assessment techniques - answerInspection (1)
Palpation (2)
Percussion (3)
Auscultation (4)
Skin Color Assessment - answerJaundice- yellow
Cyanosis- blue
Erythema- red
Pallor- pale
Vitiligo- whitish patches on the skin
, Tanned or brown
Patients with Skin Cancer: ABCDE - answerA - Asymmetry
B - Boarder irregular
C - Color variegated
D - Diameter > 6 mm
E - Enlarging
Moles, irregular pattern, bumpy, change in color
Equipment for Assessment of the head and neck - answerpen light
tongue depressor
gloves
Assessment of the Eyes - answerSnellen chart measures visual acuity, pupil size
PERRLA (Pupils Equal Round Reactive to Light & Accomodation)
Accommodation- start with the object far then move it far looking for the pupils to dilate
when object is closer,
Convergence when the eyes cross or go in on the object
Extraocular movements- cardinal directions, Both eyes are coordinated, parallel, making
the H
Visual Acuity
Snellen Chart
20/20 vision (20/30 or 20/50
Peripheral Vision
Equal on both side
Normal Lung sounds - answerBronchial Sounds
Bronchovesicular Sounds
Vesicular Sounds
Bronchial Sounds - answerHeard over lungs and trachea
High-pitched, harsh "blowing" sounds
Bronchovesicular - answerHeard over mainstem bronchus
Heard posteriorly between scapula and anteriorly lateral to sternum
