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How would you describe a pulse when documenting -
ANSWER--82 beats per
minute, regular, and
strong
A client asks you why you are checking their blood pressure.
What is the best
response - ANSWER--"To check the health of your heart
and circulation
system"
What is the most important thing to ensure client safety
with orthostatic
hypotension - ANSWER--Get client to stand
up slowly
,How would you document pitting edema in bilateral ankles
- ANSWER--3+
pitting edema, bilateral ankles, skin pale
and shiny
How would you describe a stage 1 decubitus (pressure) ulcer
when documenting - ANSWER--Left heel, skin intact, local
redness, branches to touch
How would you document a "normal" peripheral
circulation - ANSWER--
Peripheral pulses are strong and regular
bilaterally
What is a "normal" inspection finding when inspecting the
neck - ANSWER--
Thyroid gland moves up with
swallowing
Which abnormalities have the most significant impact on
nutritional status -
ANSWER--Lactose and gluten intolerance,
and diabetes
How would you document an abnormal abdominal assessment
- ANSWER--
Distended and firm, bowel sounds are hypoactive, left lower
quadrant, active X3 quadrants
,Which location would you be likely to see herniation on
the abdomen -
ANSWER--Umbilicus, surgical
scars, inguinal
During abdominal palpation, you notice guarding and
grimacing. What would
you further assess - ANSWER--Subjective pain
assessment
How would you assess internal rotation of the shoulder -
ANSWER--Hands
behind
head
Which joints are not capable of hyperextension - ANSWER--
Knees and elbows
How would you document the uncoordinated irregular gait
of your client -
ANSWER--Ataxia with
ambulation
What should be included in the subjective
musculoskeletal assessment -
ANSWER--Functional
assessment
, How would you document "normal" musculoskeletal
assessment findings - ANSWER--Normal muscle tone, full ROM
to all joints, muscle strength is 5/5
After a stoke your client experiences aphasia. What does
that mean? -
ANSWER--Unable to
speak
Which cranial nerve damage would cause drooping of the
corner of the mouth
and eyelid - ANSWER--Cranial nerve
VII Facial
What does the romberg test assess - ANSWER-Cerebellar
function and
balance
What is assessed when completing a glasgow coma scale -
ANSWER--Eye
opening, verbal response, motor
response
What would you document for "normal" assessment findings for
cranial nerve III
occulomotor - ANSWER-
PERRLA