!! PNUR 103 Vitals & HeadToToe Assess

Skin inspection and palpation includes assessment for:

A. Color,

B. Skin lesions

C. Skin temperature

D. All of the above

D. All

Normal range for pulse is?

60-100

Normal range for diastolic is?

60-90 MM Hg

Normal range of respirations for an adult would be

12-20 breaths/min

Normal range for systolic is?

100-140 MM Hg

which of the following is normal temp range for adults

97 to 98.8 F

The apical pulse is located

apex of the heart

apical pulse is counted

on left side just below the nipple, one full minute

Where is the brachial pulse located

inside of the elbow at the antecubital space.

dyspnea refers to:

difficulty breathing

Crackles, Rhonchi, wheezes, and Stridor are all examples of

abnormal lung sounds

Where is the S1 and S2 heard equally?

Erb's point

What does PERRLA stand for?

pupils equal, round, reactive to light and accommodation

which are the best places to check the skin turgor?

forearm and sternum

In which position should the patient be placed in order to palpate the popliteal pulse?`

Have the patient lie prone with the knee flexed.

What is a depression that is left after pressing a finger or thumb on swollen tissue called?

Pitting edema

Normal capillary refil is less than 3 seconds and is assessed by:

Pressing on the nail bed until it blanches, and observing how quickly full

When should you check the patient''s blood pressure to assess for orthostatic hypotension

While the patient is laying, sitting and standing

Which structures are in a complete assessment of the mouth?

Lips, mucosa, and gums, teeth or dentures, tongue and floor of the mouth

Which term tells us about a person's movement

Range of Motion (ROM)

To palpate means to "feel" the patient in a light, moderate, or deep touch

true

All body systems should have the inspection technique of assessment

true

which body system requires assessment techniques in the following manner: inspect, auscultate, palpate, percuss

gastrointestinal

Symptoms refer to subjective indications of illness

true

signs refers to subjective indications of illness

false

Cardinal signs of infection and inflammations are

warmth, erythema, edema.