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09 EMR Patient Assessment New Exam With
100% Verified Answers
Accessory muscles - ANSWER The secondary muscles of respiration, they include the neck muscles (sternocleidomastoids), the chest pectoralis major muscles, and the abdominal muscles
Altered mental status - ANSWER Any deviation from alert and oriented to person, place, time, and event, or any deviation from a patients normal baseline mental status
Auscultate - ANSWER to listen to sounds within the body
AVPU scale - ANSWER A method of assessing the level of consciousness by determining whether the patient is awake and alert, responsive to verbal stimuli or pain, or unresponsive; used principally early in the assessment process
Blood pressure - ANSWER Pressure that the blood exerts against the walls of the arteries as it passes through them
Bradycardia - ANSWER Slow heart rate, less than 60 beats/min
Breath sounds - ANSWER An indication of air movement in the lungs, usually assessed with a stethoscope
Capillary refill - ANSWER A test that evaluates distal circulatory system function by squeezing (blanching) blood from an area such as a nail bed and watching the speed of its return after releasing the pressure
Carbon dioxide - ANSWER Is a component of air and typically makes up 0.3% of air at
sea level, also a waste product exhaled during expiration by the respiratory system
Chief complaint - ANSWER The reason a patient called for help, also, the patients response to questions such as "What's wrong?" or "What happened?"
Crackles - ANSWER Crackling, rattling breath sound that signals fluid in the air spaces of the lungs
Crepitus - ANSWER A grating or grinding sensation caused by fractured bone ends or joints rubbing together, also air bubbles under the skin that produce a crackling sound or crinkly feeling
Cyanosis - ANSWER A bluish gray skin color that is caused by a reduced level of oxygen in the blood
DCAP-BTLS - ANSWER A mnemonic for assessment in which each area of the body is evaluated for Deformities, Contusions, Abrasions, Punctures/penetrations, Burns, Tenderness, Lacerations, and Swelling
Diaphoretic - ANSWER Characterized by light or profuse sweating
Diastolic pressure - ANSWER The pressure that remains in the arteries during the relaxing phase of the heart's cycle (diastole) when the left ventricle is at rest
Distracting injury - ANSWER Any injury that prevents patient from noticing other injuries he or she may have, even severe injuries, for example, a painful femur or tibia fracture that prevents that patient from noticing back pain associated with a spinal fracture
Focused assessment - ANSWER A type of physical assessment that is typically performed on patients who have sustained nonsignificant mechanisms of injury or on responsive medical patients, this type of examination is based on the chief complaint and focuses on one body system or part
Nasal flaring - ANSWER Widening of the nostrils, indicating that there is an airway obstruction
NOI (nature of illness) - ANSWER General type of illness a patient is experiencing
OPQRSTU - ANSWER A mnemonic used in evaluating a patient's pain: onset, provocation/palliation, quality, region/radiation, severity, timing, and patient actions.
Orientation - ANSWER The mental status of a patient as measured by memory of person (name), place (current location), time (current year, month, and approximate date), and event (what happened)
Palpate - ANSWER To examine by touch
Paradoxical motion - ANSWER The motion of the portion of the chest wall that is detached in a flail chest, the motion — in during inhalation, out during exhalation — is exactly the opposite of normal chest wall motion during breathing
Perfusion - ANSWER Flow of blood through body tissues and vessels
PPE (personal protective equipment) - ANSWER Protective equipment that blocks exposure to a pathogen or a hazardous material
Pertinent negatives - ANSWER Negative findings that warrant no care related to incident
Priapism - ANSWER A painful, tender, persistent erection of the penis, can result from spinal cord injury, erectile dysfunction drugs, or sickle cell disease
Primary assessment - ANSWER A step within the patient assessment process that identifies and initiates treatment of immediate and potential life threats
Pulse - ANSWER The pressure wave that occurs as each heartbeat causes a surge in the blood circulating through the arteries
Pulse oximetry - ANSWER An assessment tool that measures oxygen saturation of hemoglobin in the capillary beds
Reassessment - ANSWER A step within the patient assessment process that is performed at regular intervals during the assessment process to identify and treat changes in a patient's condition, a patient in unstable condition should be reassessed every 5 minutes, whereas a patient in stable condition should be reassessed every 15 minutes
Responsiveness - ANSWER The way in which a patient responds to external stimuli, including verbal stimuli (sound), tactile stimuli (touch), and painful stimuli
Retractions - ANSWER Movements in which the skin pulls in around the ribs during inspiration
SAMPLE history - ANSWER A brief history of a patient's condition to determine signs and symptoms, allergies, medications, pertinent past history, last oral intake, and events leading to the injury or illness
Scene size-up - ANSWER A step within the patient assessment process that involves a quick assessment of the scene and the surroundings to provide information about scene safety and the mechanism of injury or nature of illness before you enter and begin patient care
Secondary assessment - ANSWER A step within the patient assessment process in which a systematic physical examination of the patient is performed, the examination may be a systematic full-body scan or a systematic assessment that focuses on a certain area or region of the body, often determined through the chief complaint
Tachycardia - ANSWER Rapid heart rate, more than 100 beats/min
Tidal volume - ANSWER The amount of air (in milliliters) that is moved in or out of the lungs during one breath
Tripod position - ANSWER An upright position in which the patient leans forward onto two arms stretched forward and thrusts the head and chin forward
Two- to three-word dyspnea - ANSWER A severe breathing problem in which a patient can speak only two to three words at a time without pausing to take a breath
Vasoconstriction - ANSWER Narrowing of blood vessels
Vital signs - ANSWER The key signs that are used to evaluate the patient's overall condition, including respirations, pulse, blood pressure, level of consciousness, and skin characteristics
Wheezing - ANSWER High-pitched, whistling breath sound that is most prominent on expiration, and which suggests an obstruction or narrowing of the lower airways, occurs in asthma and bronchiolitis
Aspiration - ANSWER Breathing fluid, food, vomitus, or an object into the lungs
assessment-based care - ANSWER A system of patient evaluation in which the chief complaint of the patient and other signs and symptoms are gathered. The care given is based on this information rather than formal diagnosis.
Bounding pulse - ANSWER A pulse with an increased volume that feels very strong and full
Thready pulse - ANSWER A pulse with a decreased volume that feels weak and thin
brachial pulse - ANSWER pulse located in the upper arm between the elbow and shoulder. Primarily used for checking pulse in infants.
carotid artery - ANSWER artery on each side of the neck that supplies blood to the head
carotid pulse - ANSWER the pulse felt along the large carotid artery on either side of the neck
flail chest - ANSWER A condition that occurs when three or more ribs are each broken in two places and the chest wall lying between the fractures becomes a free-floating segment.
posterior tibial pulse - ANSWER Pulse felt on medial side of foot, posterior to ankle
radial pulse - ANSWER beating or throbbing felt over the radial artery, usually palpated over the groove along the thumb side of the inner wrist
