4 main headings for mental status examination Correct Answer
A - Appearance
B - Behavior
C - Cognition
T - thought processes
abdomen percussion Correct Answer -general tympany: lightly
percuss in all 4 quadrants; move CLOCKWISE; air in the
intestines rises to the surface when supine
-dullness: distended bladder; adipose tissue; fluid; mass
-hyperresonance: gaseous distention
abduction Correct Answer movement of extremity away from
midline of body
acute care in spiritual care Correct Answer display soothing
presence and supportive touch; support systems provide patients
with greatest sense of well-being and serve as a human link that
connects the patient, nurse, and patient's lifestyle before an
illness; family, friends, and pastoral care are sources of faith and
hope. supporting rituals may include clergy visits, prayer,
meditations, and music
adduction Correct Answer movement of extremity toward
midline of body
aim of optimal functioning Correct Answer simultaneous life
satisfaction in work, caring relationships, and within the self
aortic area Correct Answer 2nd intercostal space right sternal
border
aphasia Correct Answer the loss of ability to speak or write
coherently or to understand speech or writing coherently or to
understand speech or writing due to a cerebrovascular accident
apical impulse Correct Answer a normal pulsation located over
the apex of the heart, at the 5th ICS medial to the MCL
-created as the left ventricle rotates against the chest wall during
systole
assess patient's spiritual viewpoints Correct Answer -because
spirituality is deeply subjective, it means different things to
different people
-recognize significance that spirituality has for all types of
health problems
-a patient's readiness for enhanced spiritual well being is based
on defining characteristics that show a person's ability to
experience and integrate meaning and purpose in life through
connectedness with self and others
-ask direct questions, and utilize spiritual assessment tools:
BELIEF (belief, ethics, lifestyle, involvement, education, future
events); FICA (faith, influence, community, address)
, attention span and abnormal findings Correct Answer check
person's ability to concentrate by noting whether they complete
a thought without wandering
-abnormal findings: is commonly impaired in people who are
anxious, fatigued, or intoxicated
babinski(plantar reflex) reflex Correct Answer -cutaneous
reflex
-stroke sole on lateral edge and across ball of foot
-expected response: toes flex or remain still
-abnormal response: fanning of toes,extension of great toe; may
indicate a pyramidal tract lesion (this reflex is considered
normal in an infant, should disappear by age 1)
ball and socket Correct Answer -shoulder and hip
biceps reflex Correct Answer -palpate the bicep tendon in the
antecubital fossa
-strike your THUMB
-expected response: plapable flexion of the elbow
body movements Correct Answer typically should be
voluntary, deliberate, coordinated, smooth, and even
bowel sounds Correct Answer -normal 5-30 per minute
-hypoactive less than 5/minute
-hyperactive more than 30/minute
-borborygmus: stomach growling heard without a stethoscope
-absent sounds: must listen for 5 minutes; decreased intestinal
motility; paralytic ileus; late bowel obstruction; peritonitis;
appendicitis
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