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NSG 207 EXAM 2 2025 VERIFIED QUESTIONS
AND ANSWERS GRADED A+
What does each letter stand for pertaining to the HEADS assessment tool?
H- Home and environment
E- Education and employment
A- Activities
D- Drugs
S- Suicide/depression
What are nursing actions are done in preparation of the physically setting before conducting an assessment?
- comfortable, warm temperature
- warm blanket if room temp can't be adjusted
- private area free of interruption
- quiet area with adequate lighting
- firm examination table at proper height
- bedside table/tray to hold equipment
How does a nurse prepare oneself before performing an assessment?
assess own feelings and anxieties before exam. Prevent transmission of infectious agents
What are the standard precautions for all patients?
Hand hygiene, gloves, skin and nail care, respiratory hygiene
What is the best position for the patient to be in when the nurse is auscultating the lungs?
sitting or standing
Explain the nursing process of insepection.
The use of sense, vision, smell, and hearing. Look and observe before touching. Expose only the body part that is being examined.
Define palpation
using parts of the hand to touch and feel for texture, temperature, moisture, mobility, consistency, and strength of pulses.
What are the different types of palpation?
light, moderate, deep, and bimanual
What are the different types of percussion?
direct, blunt, and indirect/mediate
What is the first part of a physical examination?
general survey
What is included in a general survey?
Physical development and body build
Gender and sexual development
Apparent age as compared to reported age
Skin condition and color
Dress and hygiene
Posture and gait
Level of consciousness
Behaviors, body movements, and affect
Facial expression
Speech
Vital signs
What is normal temperature? Hypothermia? Hyperthermia?
normal: 36.7°C - 37.7°C
Hypothermia: <36.5°C (96°F)
Hyperthermia: >38.0°C (100°F)
What is the normal pulse rate?
Tachycardia? Bradycardia?
Normal: 60-100 bpm
Tachycardia: >100 bpm
Bradycardia: <60 bpm
When taking a patients pulse, how is amplitude classified?
0: Absent
1+: weak, diminished
2+: normal
3+: bounding
What is a normal oxygen level? What about a patient who suffers from chronic disease?
94%-99%
chronic disease: 85%-93%
What is a typically blood pressure reading?
120/
What are factors that affect blood pressure?
cardiac output, elasticity of arteries, blood volume, blood velocity, and blood viscosity
What is Tissue or Local Perfusion?
The volume of blood that flows to target tissue
What is required for adequate tissue/local perfusion?
patent vessels, adequate hydrostatic pressure, and capillary permeability
Impaired Central Perfusion (what is it? what happens when left untreated?
Impaired central perfusion occurs when cardiac output is inadequate. Reduced cardiac output results in a reduction of oxygenated blood reaching the body tissues (systemic effect)
Severe cases are associated with shock. If left untreated, leads to ischemia, cell injury, and even cell death.
Impaired Tissue (local) Perfusion (what is it? what happens when left untreated?
impairment of tissue perfusion is associated with loss of vessel patency or permeability, or inadequate central perfusion.
Results in impaired blood flow to the affected body tissue (localized effect)
If untreated, leads to ischemia and ultimately cell death
Who is at greatest risk for impaired perfusion?
middle-ages and older adults, men, and african americans
What are the s/s of inadequate central perfusion in infants?
poor feeding, poor weight gain, failure to thrive, and dusky color
What are the s/s of inadequate central perfusion in toddlers and children?
squatting and fatigue as well as developmental delay (failure to hit milestones)
What diagnosis tests could be performed on a patient suspected of having impaired perfusion?
Laboratory tests (creatine kinase, latic dehydrogenase, troponin, C-reactive protein, serum lipids, platelets, PT, PTT, INR), electrocardiogram, cardiac stress tests (exercise or pharmacological tests), and radiographic studies (chest x-ray, ultrasound, arteriogram).
What are collaborative interventions for a patient that has been diagnosis with impaired perfusion?
diet modification, smoking cessation, increased activity (conditioning), and/or pharmocotherapy
What types of pharmacotherapy can be used to treat impaired CENTRAL perfusion?
antihypertensives, antiarrhythmics, inotropics, antianginal agents, vasopressors, vasodilators
What types of pharmacotherapy can be used to treat impaired TISSUE (LOCAL) perfusion?
Anticoagulants, thrombolytics, vasodilators, lipid-lowering agents, anti-platelet agents, and platelet inhibitors
Define anoxia
severe hypoxia or no oxygen
What are potential causes of impaired gas exchange?
ineffective ventilation
inadequate perfusion
reduced capacity for gas transportation (reduced hemoglobin and/or red blood cells)
What are individual risk factors for impaired gas exchange?
age, smoking, brain injury, decreased cognitive state, prolonged, immunosuppression, prescence of chronic medical conditions (COPD, CF, HF)
What is the nurse assessing when performing the history portion of a respiratory assessment?
past medical history/family medical history
current medication
lifestyle behaviors
social environment
occupation
problem based history
What is a nurse assessing during the examination portion of a respiratory assessment?
vital signs (HR, RR, BP, temp., and oxygen saturation)
Inspection (breathing effort, skin color, thorax, and extremities)
Auscultation of lung sounds.
What are common diagnostic tests for a patient with impaired gas exchange?
Laboratory tests (arterial blood gases, CBC, and sputum biopsy)
Radiologic studies (chest x-ray, CT and MRI scans, and ventilation/perfusion scan, positron emission tomography (PET) scan)
Endoscopy
pulmonary function studies.
What are collaborative interventions that can be put in place for a patient diagnosed with impaired gas exchange?
smoking cessation, pharmacology, nutrition therapy, positioning, chest physiotherapy, postural drainage, oxygen therapy, airway suctioning, mechanical intubation, endotracheal tubes/tracheostomy tubes, and chest tube management.
Define mental status
the level of cognitive functioning (thinking, knowledge, problem solving) and emotional functioning (feelings, mood, behaviors, stability)
What is the nursing role pertaining to mental heath?
What objective data should be collected pertaining to mental health?
posture, gait, body movements
behavior and affect
dress and grooming
hygiene
facial expresions
speech (pitch, volume clarity, logical),
moods,
cognitive abilities
the use of an assessment tool (glasgow coma scale, C-SSRS), SAD PERSONS suicide risk assessment tool, SLUMS, etc...)
What is SLUMS used for?
mental status
What are the three aspects of the Glasgow coma scale?
eye opening response
most appropriate verbal response
most integral motor respose
What does a score of 8 or less indicate when using the Glasgow coma scale?
comatose patient
What does each letter stand for in SAD PERSONS
Sex
Age
Depression
Previous attempt
Ethanol abuse
Rational thinking loss
Social support loss
Organized plan
No spouse
Sickness
What are some of the warnings of Alzheimer Disease?
asking same question over and over
repeating the same story, word for word, over and over
forgetting how to cook, do repairs, play cards, other tasks that were done regularly
losing ability to pay bills/balance checkbook
Getting lost in familiar surroundings/misplacing items
What does the Clinical Institute Withdrawal Assessment Scale assess?
Define coma
unresponsive to stimuli
Define dysarthria
defect in the muscles that control speech
define aphasia
difficultly producing and/or understanding language
What is wernicke aphasia?
rapid speech that doesn't make sense
what is broca aphasia?
person is aware of speech and language but speech is stunted
What are some physiologic responses to pain?
anxiety, fear, hopelessness, sleeplessness, thoughts of suicide.
decrease in cognitive function mental confusion, altered temperament.
increased RR and sputum retention, resulting in infection and atelectasis.
Decreases gastric and intestinal motility.
What is psychological pain
emotional or mental pain
What is psychosomatic or psychogenic pain?
psychological pain that becomes physical
what is nociceptive pain?
nerve receptors detecting harmful stimuli
What is neuropathic pain?
damage or dysfunction of any level of nervous system
What is inflammatory pain?
two aspects- inflammatory and immune responses accompanying and causing both nociceptive and neurologic pain and inflammatory pain syndromes
what is somatic pain?
Tool for cognitive impairment: FACES pain scale
What is a nursing assessing during a pain assessment?
location, intensity, quality, pattern, precipitating factors, pain relief, effect on ADLs, coping strategies.
What are tools used for pain assessment?
visual analog scale
numeric rating scale
numeric pain intensity scale
behavioral pain scale
verbal descriptor scale
simple descriptive pain intensity scale
graphic rating scale
verbal rating scale
memorial pain assessment card
McCaffrey Initial pain assessment tool
FACES pain scale
Explain the physiological process of addiction
neurochemical interacts within reward centers of brain. Addictice substances link to this reward center.
Neurotransmitters involved in the reward system are: dopamine, Y-aminobutyric acid (GABA), Glutamine, Acetylcholine, norepinephrine, serotonin.
What are the four consequences of addiction?
habituation, adaptation, tolerance, and withdrawal
What are the common symptoms seen with addiction?
fatigue, insomnia, headaches, anorexia, reported sexual dysfunction, reported change in mood, reported weight loss, and vague physical complaints.
