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Test 2
Care for the Visually Impaired
Assessment
Decreased Visual Acuity
Snellen Chart
Status of Corrective Lenses
Nursing Considerations
Sighted-Guide Technique
Communication
Safe Environment
Medications
Clock Technique for Food
Activities of Daily Living (ADL)
1 min
Care for the Hard of Hearing
Assessment
Normal: 0-15 dB
Rinne's Test
Weber's Test
Tinnitus
Difficulty Following Conversations
Nursing Considerations
Face Patient/Speak Clearly
Rephrase Misunderstood Statements
Repeat Statements Back
Hearing Aids
Sign Language
2 mins
I-SBAR-R
Identify
Situation
Background
Assessment
Recommendation
Readback
1 min
5 Rights of Delegation
Right Task
Right Circumstance
Right Person
Right Direction/Communication
Right Supervision/Evaluation
1 min
Lung Sounds - Wheezes
Location
Throughout Lung
Description
High Pitched
Sounds Like
Musical
Cause
Air Moving through Narrowed Airways
38 secs
Lung Sounds - Crackles
Location
Lower Lobes
Description
Fine/Coarse
Sounds Like
Fine: Twisting Hair through Fingers
Coarse: Velcro
Cause
Collapsed Small Airways and Alveoli "Popping Open"
1 min
Lung Sounds - Rhonchi
Location
Trachea and Bronchi
Description
Low Pitched Rumbling
Sounds Like
Gurgling
Cause
Narrowed Airway
Secretions or Bronchospasm
49 secs
Lung Sounds - Pleural Friction Rub
Location
Anterior Lateral Lung
Description
Dry, Rubbing, or Squeaking
Sounds Like
Rubbing a Balloon with Finger
Cause
Inflamed Pleura
50 secs
Age 2 Months - Developmental Milestones
Gross Motor
Holds Head Up, But Unsteady
Fine Motor
Tracks Objects to the Midline
Language
Coos
Social / Cognitive
Social Smile
Recognizes Parents
1 min
Age 4 Months - Developmental Milestones
Gross Motor
Sits With Support
Rooting Reflex Disappears
Moro Reflex Disappears
Fine Motor
Reaches Across Midline
Language
Turns to Voice
Laughs
Social / Cognitive
Enjoys Looking Around
2 mins
Age 6 Months - Developmental Milestones
Gross Motor
Palmar Reflex Disappears
Sits Propped Up On Hands
Rolls
Fine Motor
Transfers Objects Hands to Hands
Raking Grasp
Language
Babbles
Responds to Name
Social / Cognitive
Stranger Anxiety Develops
2 mins
Age 9 Months - Developmental Milestones
Gross Motor
Pulls to Stand
Starts Cruising
Fine Motor
Three-Finger Pincer Grasp
Holds Bottle or Cup
Language
Starts Sounding "Mama" or "Dada"
Social / Cognitive
Waves Bye
Separation Anxiety
Plays Pat-A-Cake
2 mins
Age 1 Year - Developmental Milestones
Gross Motor
Stands Well
First Steps
Throws Ball
Points to Objects
Babinski Reflex Disappears
Fine Motor
Two-Finger Pincer Grasp
Language
"Mama & Dada"
Social / Cognitive
One-Step Commands with Gesture
2 mins
Age 18 Months - Developmental Milestones
Gross Motor
Climbs Up Stairs
Runs
Fine Motor
Stacks Three Blocks
Eats with Spoon
Removes Clothing
Language
10-25 Word Vocabulary
Social / Cognitive
āMineā
Pretend Play
2 mins
Age 2 Years - Developmental Milestones
Gross Motor
Jumps
Fine Motor
Copies a Line
Stacks Six Blocks
Turns Pages
Language
Two-Word Phrases
Half of Speech is Understandable
200 Words by Age 2
Social / Cognitive
Parallel Play
Begins Toilet Training
Rapprochement
2 mins
Age 3 Years - Developmental Milestones
Gross Motor
Walks Up/Down Steps with Alternating Feet
Rides Tricycle
Fine Motor
Stack Nine Block Tower
Copies Circle
Uses Utensils
Language
Three-Word Sentences
75% Speech Understood by Stranger
Social / Cognitive
Knows Gender / Age
2 mins
Age 4 Years - Developmental Milestones
Gross Motor
Hop on One Foot
Fine Motor
Copies Square
Uses Fork Well
Language
100% Speech Understandable
Identifies Colors
Social/ Cognitive
Cooperative Play
Imaginary Friends
2 mins
Age 5 Years - Developmental Milestones
Gross Motor
Skips
Walks Backward
Fine Motor
Copies Triangle
Ties Shoelaces
Independent Dressing / Bathing
Prints Letters
Language
Counts to 10
Five-word Sentences
Friends
Social / Cognitive
Uses Toilet Independently
2 mins
Prevention of Falls
Risk Factors
Physical Aging
Polypharmacy
Environmental
Hospital / Facility Prevention
Call Light within Reach
Assistive Devices Available
Bed Alarms
Home Prevention
Improve Lighting
Remove Home Hazards
Priority Nursing Interventions
Promote Exercise
Fall Risk Assessment
2 mins
Fire - Environmental Emergencies
R.A.C.E
Rescue
Alarm
Confine
Extinguish
P.A.S.S.
Nursing Considerations
Fire Exits
Do Not Use Elevators
Manual Ventilation
2 mins
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