N190 FINAL EXAM WITH COMPLETE
SOLUTIONS
The different types of assessment techniques? -ANSInspection
Palpation
Percussion
Auscultation
Which technique should the nurse use initially for each specific assessment? -
ANSInspection
Assessment technique to illicit a diaphragmatic excursion? -ANSPercussion
Technique used to listen to heart sounds? -ANSAuscultation
Technique used to listen to crepitus who sustained a chest injury? -ANSPalpation
What is the technique used to assess distended bladder? -ANSDirect percussion
What is the technique used to assess sinus infection? -ANSDirect Percussion
What is the technique used for percussion of the lungs? -ANSIndirect Percussion
Identify the most common equipment used in the clinical area
Goniometer
Doppler
Wood lamp
Skin fold caliper
Transilluminator
Stabio
Stethoscope
Ophthalmoscope -ANSGoniometer: measure the degree of joint extension and flexion
Doppler: Asses non palpable pulses
Wood lamp: presence of fungal infection of skin
Skinfold Caliper: Measure thickness of subcutaneous tissue
Transilluminator: Use to detect blood, solid or fluid or mass in body cavities
Stabio meter: Height of pt.
,Stethoscope, penlight
Ophthalmoscope: red reflex
Grading for pulses -ANS0 : absent
1+: weak thready
2+: normal
3+: brisk
4+: bounding
Location of pulses -ANSPopliteal : behind the knees
Femoral: inguinal area
What part of your hand do you use to assess skin temperature? -ANSDorsal part of
hand
What part of your hand do you use to use percussion? -ANSTip of middle finger
Identify different types of lesions
Annular
Target
Dicerete
Confluent
Linear
Grouped -ANSAnnular: one circle
Target: concentric circles (more than one circle of color)
Discrete: separated
Confluent: runs together
Linear: form a line
Grouped: Together
Wheal lesion -ANSLesion caused by insect bite or hive
redden irregular border
Vesicle -ANSElevated lesion round or oval filled with clear fluid
Smaller vesicle vs bulla
Bulla Lesion -ANSLarger vesicle
More than 0.5 cm
, How do you grade edema -ANS0: no edema
1+: 2mm
2+: 4mm
3+: 6mm
4+: 8mm
Cranial Nerves -ANSI: olfactory : 2 senses
II: optic : Snellen Chart
III: oculomotor : PERRLA and Cardinal field of gaze
IV: trochlear: PERRLA and Cardinal field of gaze
V: trigeminal : TMJ
VI: abducens :PERRLA and Cardinal field of gaze
VII: facial : Smile, frown, puff cheeks, raise eyebrows
VIII: vestibulocochlear : Whisper test and Rombergs test
IX: glossopharyngeal: Hold trachea, swallow, tongue depressor
X: vagus: Swallow and repeat phrase
XI: accessory : Move shoulders up and down with and without resistance
XII: hypoglossal: Stick tongue out, side to side, up and down
10 Lymph nodes -ANS1. Periauricular: in front of ear
2. Postauricular: back of ear
3. Occipital: behind head
4. Sub mental: under front chin
5. Submandibular: under side of jaw
6. Retropharyngeal or tonsillar: under upper part of jaw
7: Superficial cervical chain: front of sternocleidmastoid
8. Deep cervical chain: deep in the sternocleidomastoid muscle
9. Posterior cervical chain: behind sternocleidomastoid
10. Supraclavicular: above clavicle
Lymph nodes in adults versus children -ANSAdults are non palpable if palpable there is
a sign of infection
Children are palpable but still need to see provider
SOLUTIONS
The different types of assessment techniques? -ANSInspection
Palpation
Percussion
Auscultation
Which technique should the nurse use initially for each specific assessment? -
ANSInspection
Assessment technique to illicit a diaphragmatic excursion? -ANSPercussion
Technique used to listen to heart sounds? -ANSAuscultation
Technique used to listen to crepitus who sustained a chest injury? -ANSPalpation
What is the technique used to assess distended bladder? -ANSDirect percussion
What is the technique used to assess sinus infection? -ANSDirect Percussion
What is the technique used for percussion of the lungs? -ANSIndirect Percussion
Identify the most common equipment used in the clinical area
Goniometer
Doppler
Wood lamp
Skin fold caliper
Transilluminator
Stabio
Stethoscope
Ophthalmoscope -ANSGoniometer: measure the degree of joint extension and flexion
Doppler: Asses non palpable pulses
Wood lamp: presence of fungal infection of skin
Skinfold Caliper: Measure thickness of subcutaneous tissue
Transilluminator: Use to detect blood, solid or fluid or mass in body cavities
Stabio meter: Height of pt.
,Stethoscope, penlight
Ophthalmoscope: red reflex
Grading for pulses -ANS0 : absent
1+: weak thready
2+: normal
3+: brisk
4+: bounding
Location of pulses -ANSPopliteal : behind the knees
Femoral: inguinal area
What part of your hand do you use to assess skin temperature? -ANSDorsal part of
hand
What part of your hand do you use to use percussion? -ANSTip of middle finger
Identify different types of lesions
Annular
Target
Dicerete
Confluent
Linear
Grouped -ANSAnnular: one circle
Target: concentric circles (more than one circle of color)
Discrete: separated
Confluent: runs together
Linear: form a line
Grouped: Together
Wheal lesion -ANSLesion caused by insect bite or hive
redden irregular border
Vesicle -ANSElevated lesion round or oval filled with clear fluid
Smaller vesicle vs bulla
Bulla Lesion -ANSLarger vesicle
More than 0.5 cm
, How do you grade edema -ANS0: no edema
1+: 2mm
2+: 4mm
3+: 6mm
4+: 8mm
Cranial Nerves -ANSI: olfactory : 2 senses
II: optic : Snellen Chart
III: oculomotor : PERRLA and Cardinal field of gaze
IV: trochlear: PERRLA and Cardinal field of gaze
V: trigeminal : TMJ
VI: abducens :PERRLA and Cardinal field of gaze
VII: facial : Smile, frown, puff cheeks, raise eyebrows
VIII: vestibulocochlear : Whisper test and Rombergs test
IX: glossopharyngeal: Hold trachea, swallow, tongue depressor
X: vagus: Swallow and repeat phrase
XI: accessory : Move shoulders up and down with and without resistance
XII: hypoglossal: Stick tongue out, side to side, up and down
10 Lymph nodes -ANS1. Periauricular: in front of ear
2. Postauricular: back of ear
3. Occipital: behind head
4. Sub mental: under front chin
5. Submandibular: under side of jaw
6. Retropharyngeal or tonsillar: under upper part of jaw
7: Superficial cervical chain: front of sternocleidmastoid
8. Deep cervical chain: deep in the sternocleidomastoid muscle
9. Posterior cervical chain: behind sternocleidomastoid
10. Supraclavicular: above clavicle
Lymph nodes in adults versus children -ANSAdults are non palpable if palpable there is
a sign of infection
Children are palpable but still need to see provider
