Exam 1

Question 1

6 categories to assess using Braden Scale

Answer 1

1. Sensory perception
2. Moisture
3. Activity
4. Mobility
5. Friction
6. Shear
   Braden Scale measured elements of risk that contribute to high intensity and duration of pressure or lower tissue tolerance for pressure

Question 2

Normal BP
Stage 1 BP
Stage 2 BP

Answer 2

N 120/ 80
Hypertension 130 <
Hoytpotension 110 >

Question 3

Normal heart rate
If heart rate is high what is the term?

Answer 3

60-100
Tachycardia = over 100 BPM

Question 4

• Air born precautions.
• Droplet precautions

Answer 4

Vesicle- Chicken pox
MRSA

Question 5

• Factors that place patients at a higher risk for skin cancer
• what is the mnemonic to help with skin cancer screening?

Answer 5

• Family history, burning/ being in the sun
• A symmetry
• B orders
• C olor
• D iameter
• E levated

Question 6

How do you assess skin turgor?

Answer 6

Pinch the skin at the clavicle or back of hand.
On the clavicle normal = less than 2 second return
On hand normal = less than 1-2 second return
If greater that 3 t-here is a serious hydration problem

Question 7

Characteristics to note/ assess when taking a pulse

Answer 7

Rate, rhythm, elasticity, contour, amplitude
0 absent
+1 weak
+2 normal
+3 bounding

Question 8

Steps of the health assessment

Answer 8

Assessment, diagnosis, planning, implementation, evaluation

Question 9

Describe a general survey

Answer 9

• Introduction
• Explanation
• Basic information
• Get supplies
• Provide Privacy
  Observing in a grocery store
  All objective data

Question 10

Types of nursing diagnoses

Answer 10

-Problem focused
-Risk for diagnosis
- Syndrome

Question 11

Type of pain that causes sensation of pain in body region distant from the actual source of pain

Answer 11

Referred

Question 12

Purulent Drainage
Serous
Sanguineous

Answer 12

Purulent: puss. white, yellow or brown, sign of infection
Serous- Clear fluid (plasma)
Sanguineous: leaking of blood; fresh leakage

Question 13

Pain associated with nervous system/ nerve damage: tingling, numbness

Answer 13

Neuropathic pain

Question 14

What is clubbing of the fingernails and what does this mean?

Answer 14

Hypoxia and liver issues

Question 15

Physical exam techniques in order

Answer 15

• Inspection
• Palpation
• percussion
  -Auscultation

Question 16

Name some physiological responses to pain

Answer 16

• elevated heart rate and respiration
  -Grimmace on face or body tension

Question 17

Types of health assessment

Answer 17

Initial, Ongoing, Focus, emergency

Question 18

Proper order for taking vital signs

Answer 18

• Temp
• Pulse
• Respirations
• O2
• blood pressure
• Pain

Question 19

Characteristics of skin

Answer 19

-Largest organ of the body
- Protects underlying tissues
- Helps maintain body temp, fluid/ electrolyte balance
- Sensation, immunity, vitamin D synthesis, part of individual identity

Question 20

Objective Data vs. Subjective

Answer 20

Objective: factual information that can be observed or measured
Ex. Vital signs, assessment observations
Subjective: anything the patient tells you about themselves
Ex. patient description of pain, emotions …

Question 21

Temp in cellcius

Answer 21

• Oral/tympanic: 37 C
• Rectal: 37.5 C
• Axillary: 36.5 C
  *temps range 96.8 to 100.4 F

Question 22

3 main components of a nursing diagnosis

Answer 22

1. Problem statement: patients current health problem
2. Etiology or related factors: possible reasons for the problem
3. Defining characteristics: signs and symptoms

Question 23

Another word used for bruise

Answer 23

Ecchymosis

Question 24

The steps used to assess pain?

Answer 24

-C haracter
- O nset
- L ocation
- D uration
- S everity
- P attern
- A ssociated

Question 25

What does AVPU stand for?

Answer 25

Alert
Verbal stimuli
Painful stimuli
Unresponsive