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Nur 265 Final Exam Questions
withAnswers
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.
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 Plaque - right answer--a solid mass greater than 1 cm in diameter and limited to the surface of the skin Example: Psoriasis and eczema Wheal - right answer--small, round, raised area on the skin that may be accompanied by itching; usually seen in allergic reactions Example: Insect bite Nodule - right answer--solid, round or oval elevated lesion 1 cm or more in diameter Examples: nodules on knuckles urticaria - right answer--allergic reaction of the skin characterized by the eruption of pale red, elevated patches called wheals or hives Pustle - right answer--raised spot on the skin containing pus Example: Pimple Bulla - right answer--a large blister that is usually more than 0.5 cm in diameter Vesicle - right answer--elevated cavity containing free fluid up to 1 cm in diameter; a "blister"; clear serous fluid flows if wall is ruptured Example: Herpes
Crust - right answer--thickened, dried out exudate left when vesicles/pustules burst or dry up; color can be red-brown, honey, or yellow depending on fluid ingredients (blood, serum, pus); elevated; rough texture; dried Example: Scab Scale - right answer--compact, desiccated flakes of skin, dry or greasy, silvery or white, from shedding of dead excess keratin cells; white to tan flakey dead skin cells Example: Dry skin and psoriasis Erosion - right answer--scooped out, shallow depression in skin; superficial; epidermis lost; moist but no bleeding; heals without scar bc erosion doesn't extend into dermis; loss of superficial epidermis; skin wont be as strong as it was Example: Popped blister Excoriation - right answer--self-inflicted abrasion; superficial; sometimes crusted; scratches from intense itching; abrasion Examples:insect bites, scabies, dermatitis, varicella Fissure - right answer--linear crack with abrupt edges, extends into dermis, dry or moist; can be hard to heal 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
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% Blood pressure decreases in the 2nd trimester. If blood pressure is high put-on bed rest Edema
Cardiac Changes in Elderly - right answer--• Gradual increase in systolic BP
- Arteriosclerosis
- Left ventricular wall thickens
- Increased incidence of dysrhythmias
- EKG changes
- Orthostatic hypotension Arterial ulcer - right answer--On the foot, no blood present, dry Venous ulcer - right answer--on ankle and shin, no defined edges, oozing and bleeding. peripheral Venous disease - right answer--Skin Temp normal Increased Edema Skin is dry Hair is present Leg elevation lessens pain Pedal pulses normal Nails are normal Pain is mild to moderate Pain increases at end of day with increased edema Peripheral aterial disease - right answer--Skin temp decreased No edema Tissue thin and SHINY Hair loss Leg elevation INCREASES pain Pedal pulses diminished Yellow and thick nails Pain is severe Pain with walking relieved with rest Peripheral vascular changes in Older age - right answer--Arteries calcify Arterial walls lose elasticity and tone Superficial vessels become more prominent Increased peripheral vascular resistance Decreased venous return which can cause orthostatic hypotension Hypertension - right answer--One of the most common diseases in the world. Responsible for strokes, renal failure, and congestive heart failure.
(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 Percussion of abdomen - right answer--- percuss lightly on all 4 quadrants
- tympany should dominate b/c air rises to GI surface when pt is supine *dullness occurs over a distended bladder or solid organs *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 supination and pronation - right answer--rotational movement, results in the palm facing upward/downward rotation - right answer--turning of neck or hip Circumduction - right answer--circular movement of a limb at the far end protraction and retraction - right answer--anterior to posterior movement of scapula or mandible elevation/depression - right answer--Shoulder girdle movement upward/downward Scoliosis - right answer--abnormal lateral curvature of the spine Kyphosis - right answer--hunchback, dorsally exaggerated thoracic curvature
