NUR 101 Health Assessment.
*MIDTERM*
*PERRLA* Eye Test - correct answer*P*upils. The pupils are in the center of the iris,
which is the colored part of your eye. They control how much light enters the eye by
shrinking and widening
*E*qual. Your pupils should be the same size. If one is larger than the other, your doctor
will want to do some additional testing to figure out why.
*R*ound. Pupils should also be perfectly round, so your doctor will check them for any
unusual shapes or uneven borders
*R*eactive to. Your pupils react to your surroundings to control how much light enters
your eyes. This step reminds your doctor to check your pupils' reactions to the next two
items in the acronym.
*L*ight. When your doctor shines a light in your eyes, your pupils should get smaller. If
they don't, there could be a problem affecting your eyes
*A*ccommodation ability to see things that are both close up and far away. If your pupils
are nonreactive to accommodation, it means they don't adjust when you try to shift your
focus to an object in the distance
6 Cardinal Positions of Gaze - correct answer*AKA Diagnostic Positions Test*
- Client holds head steady & follows finger or penlight with eyes only -> Hold target 12
inches back
Move to 6 positions -> Hold momentarily, then back to center, progress clockwise
*Normal: Parallel tracking both eyes* ->
Note any *nystagmus*
- Mild: Normal at extreme lateral gaze
- Abnormal any other position
Note upper lid overlaps superior iris
- Even with downward movement
- *Lid lag occurs with hyperthyroidism*
8 Characteristics of Pain Assessment - correct answer1) Location
2) Character or quality
,3) Quantity or severity
4) Timing - onset, duration, frequency
5) Setting
6) Aggravating or relieving factors
7) Associated factors
8) Client's perception
Actual Nursing Diagnosis - correct answer- A problem validated by the presence of
major defining characteristics
- Consists of 3 parts:
1. *Diagnostic label*
2. *Contributing factors* (if known)
3. *Signs & symptoms*
"Alteration in Comfort: Pain RT surgical procedure as evidenced by elevated HR, BP
and RR, muscle tensing and grimacing and pt report of 6/10 pain on numbers scale"
Actually Taking BP - correct answer1. Place stethoscope *bell over brachial* artery
- Light but airtight seal
- Picks up low-pitched sounds
*Diaphragm adequate but is really for high pitched sounds*
2. Rapidly inflate cuff to previously determined maximum inflation level
3. Deflate slowly, about 2mmHg per heart beat
4. Note points at which you hear first appearance of sound, muffling of sound, and final
disappearance of sound
Appearance - correct answer*Posture*
- Erect and position relaxed
*Body movements*
- voluntary, deliberate, coordinated, and smooth and even
, *Dress*
- Appropriate for setting, season, age, gender, and social group
*Grooming and hygiene*
- Clean and well groomed; hair is neat and clean
- Disheveled appearance in previously well-groomed person is significant
- Use care in interpreting clothing that is disheveled, bizarre, or in poor repair, as well as
piercings and tattoos, because these may reflect person's economic status or deliberate
fashion trend, especially among adolescents
Auscultation - correct answer- Listening to sounds produced by body
- Heart, lungs, blood vessels, abdomen
- Stethoscope Earpieces point forward
-*Diaphragm* - high-pitched sounds— *breath*, *bowel*, and *normal heart sounds*.>
usually BP
- *Bell* -soft, low-pitched sounds such as extra heart sounds or *murmurs
Clean with alcohol between clients
Behavior - correct answer*Level of consciousness*
- Awake, alert, aware of stimuli, responds appropriately
*Facial expression*
- Appropriate to situation; comfortable eye contact unless precluded by cultural norm
*Speech*
- Quality and appropriateness of speech
- Pace of conversation is moderate, and stream is fluent
- Articulation
- Word choice is effortless and appropriate to educational level; person completes
sentences, occasionally pausing to think
*Mood and affect*
- "How do you feel today," or "How do you usually feel?"
- Should be appropriate to person's place and condition and should change
appropriately with topics; person is willing to cooperate
Bimanual Palpation - correct answer- Use of both hands to "trap" an organ to assess its
texture & firmness
- Use for *kidneys* and *female reproductive organs*
*MIDTERM*
*PERRLA* Eye Test - correct answer*P*upils. The pupils are in the center of the iris,
which is the colored part of your eye. They control how much light enters the eye by
shrinking and widening
*E*qual. Your pupils should be the same size. If one is larger than the other, your doctor
will want to do some additional testing to figure out why.
*R*ound. Pupils should also be perfectly round, so your doctor will check them for any
unusual shapes or uneven borders
*R*eactive to. Your pupils react to your surroundings to control how much light enters
your eyes. This step reminds your doctor to check your pupils' reactions to the next two
items in the acronym.
*L*ight. When your doctor shines a light in your eyes, your pupils should get smaller. If
they don't, there could be a problem affecting your eyes
*A*ccommodation ability to see things that are both close up and far away. If your pupils
are nonreactive to accommodation, it means they don't adjust when you try to shift your
focus to an object in the distance
6 Cardinal Positions of Gaze - correct answer*AKA Diagnostic Positions Test*
- Client holds head steady & follows finger or penlight with eyes only -> Hold target 12
inches back
Move to 6 positions -> Hold momentarily, then back to center, progress clockwise
*Normal: Parallel tracking both eyes* ->
Note any *nystagmus*
- Mild: Normal at extreme lateral gaze
- Abnormal any other position
Note upper lid overlaps superior iris
- Even with downward movement
- *Lid lag occurs with hyperthyroidism*
8 Characteristics of Pain Assessment - correct answer1) Location
2) Character or quality
,3) Quantity or severity
4) Timing - onset, duration, frequency
5) Setting
6) Aggravating or relieving factors
7) Associated factors
8) Client's perception
Actual Nursing Diagnosis - correct answer- A problem validated by the presence of
major defining characteristics
- Consists of 3 parts:
1. *Diagnostic label*
2. *Contributing factors* (if known)
3. *Signs & symptoms*
"Alteration in Comfort: Pain RT surgical procedure as evidenced by elevated HR, BP
and RR, muscle tensing and grimacing and pt report of 6/10 pain on numbers scale"
Actually Taking BP - correct answer1. Place stethoscope *bell over brachial* artery
- Light but airtight seal
- Picks up low-pitched sounds
*Diaphragm adequate but is really for high pitched sounds*
2. Rapidly inflate cuff to previously determined maximum inflation level
3. Deflate slowly, about 2mmHg per heart beat
4. Note points at which you hear first appearance of sound, muffling of sound, and final
disappearance of sound
Appearance - correct answer*Posture*
- Erect and position relaxed
*Body movements*
- voluntary, deliberate, coordinated, and smooth and even
, *Dress*
- Appropriate for setting, season, age, gender, and social group
*Grooming and hygiene*
- Clean and well groomed; hair is neat and clean
- Disheveled appearance in previously well-groomed person is significant
- Use care in interpreting clothing that is disheveled, bizarre, or in poor repair, as well as
piercings and tattoos, because these may reflect person's economic status or deliberate
fashion trend, especially among adolescents
Auscultation - correct answer- Listening to sounds produced by body
- Heart, lungs, blood vessels, abdomen
- Stethoscope Earpieces point forward
-*Diaphragm* - high-pitched sounds— *breath*, *bowel*, and *normal heart sounds*.>
usually BP
- *Bell* -soft, low-pitched sounds such as extra heart sounds or *murmurs
Clean with alcohol between clients
Behavior - correct answer*Level of consciousness*
- Awake, alert, aware of stimuli, responds appropriately
*Facial expression*
- Appropriate to situation; comfortable eye contact unless precluded by cultural norm
*Speech*
- Quality and appropriateness of speech
- Pace of conversation is moderate, and stream is fluent
- Articulation
- Word choice is effortless and appropriate to educational level; person completes
sentences, occasionally pausing to think
*Mood and affect*
- "How do you feel today," or "How do you usually feel?"
- Should be appropriate to person's place and condition and should change
appropriately with topics; person is willing to cooperate
Bimanual Palpation - correct answer- Use of both hands to "trap" an organ to assess its
texture & firmness
- Use for *kidneys* and *female reproductive organs*
