Physical Assessment and Vital Signs Practice

Comprehensive head-to-toe assessment and vital signs flashcards based on lecture notes covering nursing processes, clinical landmarks, and diagnostic cues.

What is the last step in the Nursing Process and Clinical Judgement Model where reassessment occurs?

Evaluation (Evaluate outcomes)

In the AVPU scale for consciousness, what does the letter 'V' represent?

Verbal Stimuli

What BMI value classifies a client as obese?

BMI > $30$

What BMI value classifies a client as overweight?

BMI > $25$

What BMI value classifies a client as underweight?

BMI < $18.5$

What does the acronym 'SAMPLE' stand for in a trauma survey?

Allergies, Medications, Past Medical History, Last Meal, Events Surrounding Injury

In the orientation x$4$ assessment, what are the four components a client should be oriented to?

Person, place, time, situation

According to the 'Reasons for Unconsciousness' chart, what does a red skin color indicate?

Stroke or BP

According to the 'Reasons for Unconsciousness' chart, what does white skin color indicate?

Shock or Hemorrhage

According to the 'Reasons for Unconsciousness' chart, what does blue skin color indicate?

Respiratory or Cardiac Arrest

Where is the Aortic heart sound location found?

Right $2^{nd}$ Intercostal Space

Where is the Pulmonic heart sound location found?

Left $2^{nd}$ Intercostal Space

Where is Erb's Point located?

(S1, S2) Left $3^{rd}$ Intercostal Space

Where is the Tricuspid heart sound location found?

Lower Left Sternal Border $4^{th}$ Intercostal

Where is the Mitral heart sound location found?

Left $5^{th}$ Intercostal, Medial to Midclavicular Line

What mnemonic is used to remember the five areas for listening to the heart?

All People Enjoy Time Magazine

What might brittle, dry hair indicate during a cardiac assessment?

Poor nutrition, possibly due to cardiac or vascular insufficiency

What do raised yellow-orange plaques under eyelids indicate?

Chronic serum cholesterol elevation

Blue-tinged lips or tongue (cyanosis) and dry mucous membranes (dehydration) are clues for which body system?

Cardiac / Oxygenation

What condition should you suspect if the jugular vein is distended when the client is at a $45^{\circ}$ angle?

Hypervolemia, right-sided heart failure, pericardial tamponade or constrictive pericarditis

Auscultating crackles (rales) in the chest may indicate which condition?

Left-sided heart failure

What blood pressure reading indicates potential hypertension?

Over $135/85$

In the abdomen, what might fluid accumulation (ascites) or an enlarged, tender liver indicate?

Right-sided heart failure

A pulsating mass in the abdomen may be a sign of what condition?

AAA (Abdominal Aortic Aneurysm)

What does nail clubbing indicate during a Physical Assessment?

Chronic low $O_2$ saturation, as in congenital cardiac or pulmonary disease

What are signs of poor circulation in the lower extremities?

Absence of hair and thin skin

What are the causes of heart murmurs represented by the acronym SPAMS?

Stenosis of a Valve, Partial Obstruction, Aortic Regurgitation, Mitral Regurgitation, Septal Defect

During which part of the cardiac cycle do innocent murmurs occur in children or during pregnancy?

Systole

What is the clinical significance of a diastolic murmur?

Indicates Pathologic Disease

How are Crackles described and when are they typically heard?

High Pitched, Discontinuous sounds heard during inspiration that may change with cough

How are Rhonchi described and how can they be cleared?

Rumbling, coarse sounds like a snore (continuous); may clear with coughing or suctioning

What are the characteristics of a Wheeze?

Musical noise heard during inspiration or expiration, first heard on expiration

What are the 6 Ps included in a Neurovascular Assessment?

Pain, Pulse, Pallor, Paresthesia, Paralysis, Pokliothermia

What is the depth in millimeters for $1+$ pitting edema?

$$2mm$$

What is the depth in millimeters for $2+$ pitting edema?

$$4mm$$

What is the depth in millimeters for $3+$ pitting edema?

$$6mm$$

What is the depth in millimeters for $4+$ pitting edema?

$$8mm$$

What mnemonic is used for 3-lead electrode placement?

Salt, Pepper, Ketchup

What is the specific placement mnemonic for Lead II telemetry?

White over right, and smoke (black) over fire (red)

What should be included in the General Survey?

Across the room observation (Overall appearance, work of breathing, skin color)

What is the purpose of the initial Assessment phase?

To Recognize Cues

What are the components of the 'Implementation' step in clinical judgement?

Taking Action and prioritizing interventions

What heart sounds are heard at Erb's Point?

$S_1$ and $S_2$

In the context of cardiac clues, what does pallor of the skin suggest?

Anemia or decreased circulation

Where should a nurse check for edema and pressure areas specifically in immobilized clients?

The sacrum

In 5-lead EKG placement, which lead is typically placed at the right wrist?

The White lead

What does the 'A' in the AVPU scale stand for?

Alert

What does the 'P' in the AVPU scale stand for?

Painful Stimuli

What does the 'U' in the AVPU scale stand for?

Unresponsive

What is the goal of the 'Planning' phase of the nursing process?

Prioritize Hypothesis and Generate Solutions