*NURSING > EXAM > NR509_IMMERSION_EXAM 2020 - Chamberlain College of Nursing | NR509_IMMERSION_EXAM 2020 (All)
NR509_IMMERSION_EXAM 2020 - Chamberlain College of Nursing Purple= graded aspect. Always say the cranial nerve number & name! Red = FNPS script. (black in parentheses)= patient script. Sanitize ha... nds. Hello, ______ my name is ____ and I will be assessing you today. I need you sitting up for the exam. HEAD AND FACE Inspects facial skin – note abnormal lesions; Inspect head for size, symmetry, midline position I will begin by inspecting your face, and I don't see any discolorations, or any lesions and your head is midline and symmetrical. Palpates lymph nodes of the head and neck: Preauricular, Postauricular, Occipital, Tonsillar, Submandibular, submental, Anterior Cervical, Posterior Cervical, Supraclavicular (verbalize these) PPOTSS AC PC S I will palpate your lymph nodes. First, I will begin with the preauricular lymph nodes, right in front of the ear, and postauricular, right behind the ear. Then I will palpate your occipital lymph nodes in the back of the head. And then I will move forward and palpate your tonsillar lymph nodes. Come under the jawline, the submandibular lymph nodes, and the submental. Now I will go to the anterior cervical lymph nodes, and the posterior cervical lymph nodes. And I will end with the supraclavicular lymph nodes right about the clavicles. I do not feel any enlargement, and they are equal bilaterally - - - - - - - - - - - - - - - - - - - - - - - - en I release, if the patient feels any pain on the rebound, that would be a positive Blumberg sign of rebound tenderness indicative of peritonitis. Any pain? (No). LOWER EXTREMITIES Inspect the skin integrity of lower extremities and assess for edema. I will assess the lower extremities. First, I will inspect the skin for any lesions or any edema. I do not see any. https://www.coursehero.com/file/36452030/NR509-IMMERSION-EXAMpdf/ This study resource was shared via CourseHero.com8 Assess passive unilateral ROM of hips (flexion, abduction, adduction, internal rotation, external rotation) *extension not tested for this exam. Assess passive unilateral ROM of the knees (flexion, extension). Assess strength at the knees (bilateral) – flex/extend against resistance – 5/5 strength. Assess passive unilateral ROM of the ankles (dorsiflexion, plantar flexion, rotation). Assess strength at ankles (bilateral) – dorsi/plantar flex against resistance – 5/5 strength. Next, I'm will check range of motion of your hip and I'm going to go ahead and flex your knee. And, in turn, flex your hip. Then, I will go into abduction, taking the leg away. And adduction, crossing the midline. Next will be internal rotation. And then external rotation. And go ahead and rest the leg. For purposes of this exam we will not be testing extension. Now I'm going to assess range and motion of the knee, flexion and extension. Now I'm going to assess the strength of your knees. Go ahead and flex your knees. I'm going to place my hands on top and ask you to push up towards them. Now push back. Very good, and your strength is five out of five and equal. Go ahead and extend your legs. Now I will do the range of motion of your ankle. Supporting the ankle, dorsiflexion, plantar flexion, and rotation. Strength is five out of five and equal. Now I will assess the strength of your ankles. And you will pull up or dorsiflex with resistance. Plantar flexion or push down with resistance. And that was five out of five and equal as well. Assess dorsalis pedis pulse Now I will assess your dorsalis pedis pulses. And they are 2+ and equal. Have patient stand up Inspect and palpate the spine – expected curvatures, alignment, tenderness. Assess active ROM of the spine (flexion, extension, lateral flexion, and rotation). For the spine examination, I'm going to inspect and palpate along both sides of the spine for any expected curvatures, alignment, and tenderness. Next, I will do range of motion of the spine. And so, I'm will ask you to go ahead and bend over and touch your toes. Now straighten back up and extend backwards. Now straighten back up and do a lateral flexion to one side and then the other. And now rotation, to the right and to the left. And you have very good, active range of motion. Assess Romberg Next, I will assess for the Romberg and I'll have you just stand with your arms down by your side. Close your eyes for about 20 seconds, and I'm looking for any swaying. And there is none. You can open your eyes. So that would be a negative Romberg. Assess gait (just several steps) Now I will assess your gait and ask you to take a few steps forward. Turn around and a few steps more [Show More]
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