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Final Exam| Nurs 300 Final Exam 2025 Applied Pharmacology
COMPLETE EXAM QUESTION AND ANSWER BYU (300 FREQUENTLY
TESTED QUESTIONS)
Braden Scale Ranks a patient's risk for the following:
- sensory perception
- moisture
- activity
- mobility
- nutrition
- friction
- shear Braden Scale Scoring lower scores = higher risks 19 - 23 = no risk 15 - 18 = mild risk 13 - 14 = moderate risk 10 - 12 = high risk 9 - below = severe risk Norton Scale Ranks based on the following:
- physical condition
- mental state
- activity
- mobility
- continence Norton Scale rankings lower score indicates higher risk
16 - 30 = low risk 11 - 15 = moderate risk 10 - below = high risk Focused Wound Assessment includes
- Location
- Size
- Presence of undermining or tunneling
- Drainage
- Wound edges and surrounding tissues
- Wound bed
- Patient response Determining size of wound measure length, width, and depth Determining undermining or tunneling
- use a cotton-tipped applicator and move under the edges of the wound
- note the presence of tunnels (these increase the size of the wound) Undermining loss of tissue around edges of wound Tunneling increase size of wound and require treatment to prevent dead space Types of drainage
- serous
- serosanguineous
- sanguineous
- purulent
wound bed documentation
- describe tissue in the wound bed (new granulated tissue, dead necrotic tissue, fatty subcutaneous tissue, bone or muscle)
- describe color and other points about appearance (beefy, red, shiny, and moist (granulation tissue) expected
- examine for pale, dry appearance and for presence of foreign antibodies, both of which can delay healing patient response documentation
- describe patient's pain in response to wound itself and in response to treatment
- describe patients emotional and psychological responses Pressure Ulcer Scale for Healing PUSH
- assigns a numerical score to pressure injuries according to 3 characteristics
- surface area of the wound
- wound exudate
- type of wound tissue Contributing factors to pressure injuries
- immobility
- incontinence of urine/stool
- excessive moisture on skin
- paralysis, sensory loss, spinal cord injury (unable to move to relieve pressure)
- unrelieved, prolonged pressure
- malnourishment
- aging
- diseases, such as diabetes, dementia, and/or brain injury Stage 1 pressure ulcer intact skin with nonblanchable erythema
Stage 2 pressure ulcer exposed dermis from loss of partial-thickness tissue Stage 3 pressure ulcer loss of full-thickness skin but no loss of underlying tissue Stage 4 pressure ulcer Full thickness skin loss with exposed muscle, bone, tendons, and/or cartilage (includes loss of tissue) Unstageable pressure ulcer eschar or other factors obscure full-thickness skin and tissue loss suspected deep-tissue pressure injury persistent nonblanchable deep red, maroon, or purple discoloration Impaired skin integrity
- focuses on epidermal and dermal layers of the skin
- damage to these layers is called impaired skin integrity Impaired tissue integrity
- focuses on subcutaneous tissues as well as muscles, bones, tendons, and cartilage
- damage to these tissues is called impaired tissue integrity Overall goals of wounds
- promotion of complete wound healing
- maintenance of intact skin
- prevention of risks associated with specific skin or wound alterations
- reduction of pain level to a 3 or lower with treatments
Alginate dressing Known for their absorptive properties o Forms a gel over the wound to contain exudate o Nonadhesive, nonocclusive that conforms to the shape of the wound o Creates a moist environment and promotes autolysis, granulation, and epithelialization o Used for full-thickness wounds with moderate-high amounts of drainage o Can pack deep tracking wounds with calcium-sodium alginate preparation o Changed as often as daily or left in place for several days Skin cleaning to maintain skin integrity
- Clean the skin as soon as possible after soiling occurs and at routine intervals
- Use a mild, heavily fatted soap or gentle commercial cleanser for incontinence
- Use tepid rather than hot water
- In the perineal area, use a disposable cleaning cloth that contains a skin barrier agent
- While cleaning, use the minimum scrubbing force necessary to remove soil
- Gently pat rather than rub the skin dry
- Do not use powders or talcs directly on the perineum
- After cleansing, apply a commercial skin barrier to those areas in frequent contact with urine or feces Neurologic assessment includes
- Orientation
- General appearance
- Cognitive abilities
- Mini-Mental State Examination (MMSE) Vital signs and their unexpected findings Temperature
- Confusion or disorientation from fever Blood Pressure
- Headache and stroke affecting all areas of cognition from hypertension
- Dizziness, loss of consciousness, and falls from orthostatic hypotension Pulse Oximetry
- Dizziness, decreased cognition/consciousness, confusion, and restlessness from low levels of oxygen (hypoxia) Orientation Disoriented for one, two, or all three areas of person, place, and/or time; recorded as disoriented x1, 2, or 3 depending on situation Appearance (unexpected finding) Disheveled, unclean, body odor Reasoning (unexpected finding) Illogically answers questions Judgement (unexpected finding) Makes inappropriate decisions (such as answers the question by saying would take 2 pills at once or take 2 the next day) Language (unexpected finding) Cannot speak, read, write, an/or receive information Mini-Mental State Examination (MMSE) Cognitive orientation
- Disoriented for one, two, or all three areas of person, place, an/or time Attention
- Fails to follow directions Calculation
- Unable to add simple numbers such as 5 + 4 Recall
- Can only remember one or two objects but not all three
DTR grading scale 0 = no response 1+ = sluggish, diminished 2+ = normal response 3+ = brisker than normal/average, slightly hyperactive 4+ = very brisk, hyperactive Babinski reflex (unexpected findings) positive test result: dorsiflexion of the big toe and fanning of the other toes usually indicates:
- infection in the brain or spinal cord
- injured spinal cord
- damage to sensory or motor neurons
- damage to the brain and/or spinal cord Cranial Nerve I: Olfactory Unexpected findings Loss of smell (age, smoking, allergies, frontal lobe lesion) Cranial Nerve II: optic Unexpected findings
- has blindness (damage to the optic nerve or occipital area of the brain)
- can only see half of the chart or printed material (CVA) Cranial Nerves III, IV, VI: Oculomotor, trochlear, abducens Unexpected Findings
- has unequal pupil sizes (increased intracranial pressure)
- has no or sluggish constriction and dilation of pupils in response to light (increased intracranial pressure)
- cannot follow the penlight, or eyes begin to quickly go side to side or up and down (eye orbit fracture, tumor of the brainstem, street drug use)
Cranial Nerves VII, IX: facial, glossopharyngeal Unexpected findings
- cannot identify tastes (aging, inflammation, tumor, or trauma) Cranial Nerves VIII: vestibulocochlear Unexpected findings
- cannot repeat whispered word (aging, inflammation, drug toxicity, ear infection, or occluded ear canal) Lab tests that have to do with cognition and sensory deficits
- electrolytes
- blood sugar
- cholesterol
- urinalysis Delirium A reversible, temporary state of confusion that occurs suddenly (over 1-2 days) causes and risks of delirium o Other medical conditions o High fever o Low spO2 sat o Medication side effects o Alcohol or substance abuse o Fluid and electrolyte imbalances o Hypoglycemia o Pain and pain medications o Infections, especially in the brain o Too much sensory stimuli, especially in ICU signs/symptoms of delirium o Fluctuations in awareness (acute confusion) o Memory impairment (loss of orientation to person, place, or time)
Depression A reversible disorder that causes the person's mood to be negative causes/risks of depression o Chemical changes in the brain o Life situations o Medication side effects o Genetic predisposition o Too little sensory stimuli signs/symptoms of depression o Decreased or loss of interest o Unhappiness for extended periods o Low self-esteem o Sleep disturbances o Eating pattern changes cerebrovascular accident (CVA) Decreased oxygen to the brain leading to ischemia and even brain cell death types of CVA ischemic and hemorrhagic causes/risks of CVA o Hypertension o Atrial fibrillation o Vascular disease signs/symptoms of CVA o FAST o Face drooping
o Arm weakness o Slurred speech o Time to call 9- 1 - 1 Signs/symptoms of right-sided stroke § Motor and sensation deficits are possible on the left side of the body because nerve impulse crosses over in the spinal cord § Visual-spatial problems may be present Signs/symptoms of left-sided stroke § Motor and sensation deficits are possible on the right side of the body because nerve impulse crosses over in the spinal cord § Speech difficulties, aphasia, may be present · Receptive aphasia (Wernicke aphasia) · Expressive aphasia (Broca aphasia) Receptive aphasia (Wernicke aphasia) o Temporal lobe damaged o Unable to understand language but can speak Expressive aphasia (Broca aphasia) o Frontal lobe damaged o Unable to speak but can understand language Myopia o Clear vision at close distance o Nearsightedness hyperopia o Clear distance vision o Farsightedness o Called "presbyopia" when related to aging and occurs gradually
Sensory deprivation An involuntary loss of physical awareness caused by a lack of external sensory stimuli causes/risks for sensory deprivation o Strict isolation for medical reasons, such as after a stem cell transplant o Hearing or visual impairment, making the patient less likely to interact with others in social situations signs/symptoms of sensory deprivation o Bored o Disinterested in caring for self o Reduced ability to think clearly Meniere disease
- An inner ear disorder that causes episodes of vertigo
- Smoking, infections, or high-salt diet may worsen the disease signs/symptoms of menière disease
- Symptoms/signs o Vertigo o Hearing loss o Tinnitus o Ear pressure symptoms of immediate concern with patients
- Becomes restless o Indicates lack of oxygen to the brain
- Begins to slur words o Potential CVA
- Begins to act confused o Indicates lack of oxygen to the brain
- Sudden droop of the fact o Potential CVA/stroke Key interventions for patients with cognitive alterations o Engage in concrete activities like "here and now" and ADLs such as folding towels o For patients with chronic confusion, distract the patient from negative behavior o Adapt the environment to the patient o Provide reality orientation o Use a clock and calendar to orient the hospitalized patient o Wear name tags o Ensure consistency in the patient's surroundings and routines o Keep the same staff members assigned to the patient o Reduce loud noises and bright lights o Provide natural lighting for orientation to time of day o Involve family members or significant others in decisions about care Physical examination: inspection Unexpected cues for urinary elimination
- Distention, masses
- Bruising or lesions
- Redness or skin breakdown Physical examination: auscultation Unexpected cues for urinary elimination bruit(s) over one or both renal arteries Physical examination: percussion Unexpected cues for urinary elimination
- Tenderness
- Unexpected fullness Physical examination: palpation Unexpected cues for urinary elimination
Low volume - urine output of less than 30mL/hr may indicate decreased kidney perfusion Expected urine output formula .5mL/kg/hr - 1.5mL/kg/hr Lab Urine Test - ordered when:
- Suspected UTI
- Suspected uncontrolled - diabetes
- Suspected kidney or urinary tract damage
- Routine screening Lab urine test: unexpected results Specific gravity LOW
- Diluted urine
- Present in FVE HIGH
- Concentrated urine
- Present in dehydration Lab urine test: unexpected results pH level LOW or HIGH
- alteration in acid-base balance
- urine with bacterial growth tests higher in pH Lab urine test: unexpected results Protein present Indicates altered kidney function Lab urine test: unexpected results
glucose present Indicates poorly controlled diabetes Lab urine test: unexpected results ketones present
- Indicates breakdown of fatty acids
- Present in poorly controlled diabetes, dehydration, or starvation Other lab tests for urine
- C&S
- creatinine clearance test (24-hour urine collection) ordered for suspected kidney damage or disease
- BUN test
- Creatinine Urinary function diagnostic tests
- ultrasound
- KUB study
- intravenous pyelography
- computed tomography
- cystoscopy
- contrast medium use in imaging Ultrasound for urinary function
- Used to assess size, shape, and location of the kidneys and bladder
- A full bladder provides the clearest imaging of urinary structures KUB study for urinary function
- Kidney, ureter, and bladder study
- Diagnostic x-ray image
- Used to detect kidney stones and assess positioning of indwelling devices such as a ureteral stent
