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Nur 265 Final Exam Questions with
Answers
Subjective data - right answer--what the person says about himself or herself during history taking Objective data - right answer--what the health professional observes by inspecting, palpating, percussing, and auscultating during the physical examination Primary data sources - right answer--From the patients or your observations Secondary data sources - right answer--From family members or other healthcare staffG General survey - right answer--study of the whole person, covering the general health state and any obvious physical characteristics Complete assessment - right answer--complete health history & full physical exam. describes the current & past health state & forms a baseline. collected by a primary physician Focused assessment - right answer--assessment conducted to assess a specific problem; focuses on pertinent history and body regions follow up assessment - right answer--it is one that is conducted at regular intervals during care of the patient; concentrates on identified health problems to monitor positive or negative changes and evaluate the effectiveness of interventions insepction - right answer--visual examination Palpation - right answer--an examination technique in which the examiner's hands are used to feel the texture, size, consistency, and location of certain body parts ascultation - right answer--listening to sounds within the body
Percussion - right answer--tapping on a surface to determine the difference in the density of the underlying structure Tympany percussion - right answer--high-pitched, loud, drum-like sound produced over the stomach dullness percussion - right answer--Fluid or mass under area being percussed First level priority - right answer--emergent, life-threatening, and immediate, such as establishing an airway or supporting breathing Second level priority - right answer--Problems next in urgency-those requiring your prompt intervention to forestall further deterioration. EX: Mental status change, untreated medical problems, acute pain, acute urinary elimination problems, abnormal lad values, or risk of infection. Third level priority - right answer--Health problems that don't fit into more severe categories. Such as lack of activity, rest or family coping. Therapeutic communication - right answer--Verbal and nonverbal communication techniques that encourage patients to express their feelings and to achieve a positive relationship. Pressure Injury Stage 1 - right answer--intact skin, non-blanchable redness Pressure Injury Stage 2 - right answer--skin loss (partial-thickness); may see a blister or shallow reddish-pink ulcer; the blister may be intact or open Pressure Injury Stage 3 - right answer--skin loss (full-thickness); skin gone; may see subcutaneous fat; slough (dead soft tissue, often moist and varies in color - white, yellow, green, or tan) may be present; could be attached or stringy loose Pressure Injury Stage 4 - right answer--full-thickness skin and tissue loss with muscle, tendon, and bone exposure; slough and eschar (thick, leathery dead tissue that may be loose or attached to skin); often black or brown unstageable pressure injury - right answer--Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. Deep tissue injury - right answer--Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.
Skin care Minimize pressure Avoid friction to skin Optimize nutrition and hydration Abnormal Lesion Assessment: ABCDE - right answer-- Asymmetry Border Color Diamete r Elevation & Evolution Primary lesion - right answer--skin lesion caused directly by a disease process; result of specific triggering agent to change previous intact skin and occur at onset of disease Secondary lesion - right answer--Evolved from original status of primary lesions; skin lesion that evolves from a primary lesion or that is caused by external forces, such as infection, scratching, trauma, or the healing process Examples of primary lesions - right answer--macule (freckle) Papule (not flat; raised) patch plaqu e wheal & urticaria nodule tumor vesicle (small clear fluid-filled lesion) Bulla (blister, can be filled like vesicle) Pustule (zit; raised, small, filled with pus) cyst (nodule filled with liquid or semisolid) Examples of secondary lesions - right answer--crust, scale, fissure, ulcer, scar, excoriation, erosion, lichenification, keloid Eccymosis - right answer--bruise Erythema - right answer--redness of the skin Macule - right answer--flat, colored spot on the
skin Example: Freckle and moles Papule - right answer--small, solid skin elevation Example: Skin tag Patch - right answer--a flat, discolored area on the skin larger than 1 cm Example: birth marks and vitiligo
Examples: cheilosis - at corners of mouth from excess moisture athlete's foot
Ulcer - right answer--deeper depression extending into dermis, irregular shape; may bleed; leaves scar when heals; tissue loss; can go into subcu tissue Example: stasis ulcer, pressure injury, chancre Scar - right answer--after a skin lesion is repaired, normal tissue is lost and replaced with connective tissue; this is a permanent fibrotic change; connective tissue will never be as strong; healed laceration is secondary lesion Example: healed wound or surgical incision or acne Keloid - right answer--benign excess of scar tissue beyond sites of original injury; looks smooth, rubbery, shiny, and claw-like; feels smooth and firm; found in ear lobes, back of neck, scalp, chest, and back; may occur months to years after initial trauma; common in ages 10-30; more common in blacks, hispanics, and asians; excessive collagen formation; could occur after burns, acne, piercings, etc Annular lesions - right answer--circular shape to skin lesion Example: Ringworm Confulent lesions - right answer--Lesions run together Ex: urticaria (hives) Discrete lesions - right answer--distinct, individual lesions that remain separate Ex: (skin tags, acne) Gyrate lesions - right answer--twisted, coiled spiral, snakelike Grouped lesions - right answer--clusters of lesion (e.g., vesicles of contact dermatitis) Linear lesions - right answer--a scratch, streak, line, or stripe Target lesions - right answer--Bullseye Example: lymes disease Zosteriform lesions - right answer--linear arrangement along a unilateral nerve route (herpes zoster) Polycyclic lesions - right answer--annular lesions grow together Example: psoriasis blood flow through cardiac valves - right answer--"Tissue Paper My Ass" Tricuspid > Pulmonic > Mitral > Aortic
causes of diastolic murmurs - right answer--aortic or pulmonic regurgitation mitral or tricuspid stenosis S1 is heard loudest where? - right answer--apex of the heart S2 is heard loudest where? - right answer--base of the heart Right sided heart failure symptoms - right answer--fatigue increased peripheral venous pressure ascites enlarged liver and spleen may be secondary to chronic pulmonary problems distended jugular veins anorexia GI distress fast weight gain dependent edema Left sided heart failure symptoms - right answer--LUNGS paroxysmal nocturnal dyspnea elevated pulmonary capillary wedge pressure pulmonary congestion (cough, crackles, wheezes, blood-tinged sputum, tachypnea) restlessness confusion orthopnea tachycardia exertional dyspnea fatigue cyanosis laying down at night may feel like person is drowning decreased SPO S3 - right answer--typically not normal, but can be normal in children, adolescents, or athletes; can also be caused by pregnancy; volume overload S4 - right answer--typically never normal; could be due to MI (heart attack) or chronic hypertension; causes: diastolic heart failure, MI, hypertrophy; abnormal, stiff ventricles
JVD and what is it a sign of - right answer--jugular venous distention; fluid overload Cardia changes during pregnancy - right answer--Anatomic changes cause pressure on the diaphragm. Blood volume increased 30-50% Increased heart rate by 10-20 BPM Cardiac output increased by 30-50%
Lymphedema - right answer--Increased lymph fluid in an area which causes unilateral swelling. Changes to lymph nodes such as removal or radiation can cause lymphedema.
Elevation, compression stocking, exercise, and massage can help reduce. Deep vein thrombosis - right answer--Risk when having recent surgery or prolonged bed rest. Being on birth control can increase risk. Trauma can increase risk. Assessment: Look for red or blue skin, edema, increased warmth Use SCDs or compression stockings to prevent blood clots when in the hospital. Promote hydration. Encourage patients to change positions frequently and do exercises in bed. vericose veins - right answer--Chronic increased venous pressure Can be removed Old age, multiple pregnancies, and prolonged standing can increase the risk. Capillary refill - right answer--after blanching nail bed, color should return to normal withing <3 secs Why do pregnant women get edema? - right answer--Being on their feet all day and hypertension Pregnant woman's blood pressure decreases-how is that possible if blood volume increases? - right answer--decrease vascular resistance AP: lateral ratio - right answer--AP should be twice the size as lateral view Adventitious lung sounds - right answer--added sounds, NOT normally heard
- crackles: fine and course
- wheeze: (or rhonchi)
- atelctatic crackles: not pathologic; short, popping, crackling, like "crackles" but don't last beyond few breaths Contour of abdomen - right answer--Normal: flat or rounded Abnormal: Scaphoid (malnourished) and protuberant (rounded) Bowel sounds - right answer--Normo active: bowel sound every 5-15 seconds Hypoactive: less than 5 every minute Hyperactive: hearing sounds every 2-3 seconds Absent only after 5 minutes of no sounds heard with a minute in each quadrant. Vascular sounds listen for bruits
*hyperresonance is present with gaseous distention Where is the liver located? - right answer--RUQ Where is the spleen located? - right answer--LUQ Correct position of the client when assessing the GI system? - right answer--Supine with legs bent upwards Abnormal female breast findings: - right answer--Dimpling: Means something underneath skin Fixation: Breast is not mobile Edema Nipple retraction Abnormal male breast findings: - right answer--Gynecomastia: enlarged breasts in children Carcinoma: skin cancer Abnormal findings in external genitalia - right answer--Pediculosis pubis: crab lice Herpes 2: genital herpes Rash: contact dermatitis HPV: genital warts Testicular Assessment and abnormal findings - right answer--Smegma- sebaceous secretion in the folds of the skin Meatus discharge/drainage Do not do assessment on prostate. Only for Nurse Practitioners and higher Testes are oval in shape and mobile. Painless lumps= cancer stress incontinence - right answer--the inability to control the voiding of urine under physical stress such as running, sneezing, laughing, or coughing Urge incontinence - right answer--involuntary leakage of urine with a sudden, strong desire to urinate Nocturia - right answer--excessive urination at night Dysuria - right answer--painful urination
flexion and extension - right answer--bending and extension of a limb adduction and abduction - right answer--towards midline/away from midline eversion/inversion - right answer--moving the sole of the foot outward or inward
Pens plantus: - right answer--flat footed Nurse maids' elbow - right answer--elbow becomes dislocated from being pulled on Check for radial pulses first to rule out broken bone
