Exam 2 Questions

Question 1

Discuss the purposes of physical assessment. (Potter 487) Ch.30

Answer 1

Use physical examination to do the following:

• Gather baseline data about the patient’s health status.
• Support or refute subjective data obtained in the nursing history.
• Identify and confirm nursing diagnoses.
• Make clinical decisions about a patient’s changing health status and management.
• Evaluate the outcomes of care. (Potter 488)

Question 2

1. Know the common causes of a urinary tract infection

Answer 2

diabetes, urinary catheters, sexual activity, contraceptives, dehydration

men: uncircumcised, large prostate

Question 3

2. Know the rules of the different transmission based precautions (airborne / contact / droplet)

Answer 3

airborne - private room with negative ventilation, wear N95 mask
Droplets - private room or someone with same disease, wear surgical mask within 3 feet
contact - private room, wear gown + gloves, when changing gloves/gowns have receptacle for them in room, wash hands with antimicrobial soap

Question 4

3. Know the rules about preparing a sterile field

Answer 4

All objects in sterile field must be sterile
Sterile objects become unsterile when an unsterile object touches them, out of vision or below waist of nurse, edges of sterile field aren’t sterile

Question 5

4. Know when it is okay to use alcohol based lotion to clean hands and when it is not

Answer 5

Alcohol based lotion: not visibly soiled, gloves off/on

Soap and water: visibly soiled or contaminated with blood or body fluids, contact with spores

Question 6

5. Know the basics of therapeutic communication

Answer 6

it is purposeful and goal-oriented, creating a beneficial outcome for the client.
goals: obtain/provide info, develop trust, show care, explore feelings

Question 7

6. Know the rules of active listening

Answer 7

client focused, encouraging, expression of feelings
techniques: clarify/validate, ask open questions, use indirect statements, reflect, paraphrase, summarize, focus, silence
Fundamentals - page 319-320
Active listening means being attentive to what a patient is saying both verbally and nonverbally. Active listening facilitates patient communication. Several nonverbal skills facilitate attentive listening. You identify them by the acronym SOLER (Townsend, 2009):
S—Sit facing the patient.
O—Observe an open posture (i.e., keep arms and legs uncrossed).
L—Lean toward the patient.
E—Establish and maintain intermittent eye contact.
R—Relax.

Question 8

7. Know the proper technique for assessing bruits on the carotid artery.

Answer 8

Place bell of the stethoscope over the carotid artery at the lateral end of the clavicle and the posterior margin of the sternocleidomastoid
muscle.
Have the patient turn his or her head slightly away from the side being examined
Ask him or her to hold the breath for a moment so breath sounds do not obscure a bruit
Palpate the artery lightly for a thrill (palpable bruit) if you hear a bruit.

Question 9

8. Know the proper technique for a respiratory assessment

Answer 9

Have patient sit up if possible
Inspect thorax for shape and symmetry. Note any deformities, position of spine, slope of ribs, or symmetric expansion during inspiration.
Observe breathing patterns - respiratory rate, rhythm, and depth
Auscultate breath sounds with diaphragm between spine and scapula and 10th and 11th vertebrae, front and back
Palpate for fremitus - feeling for vibrations while patient says “99”
Palpate for excursion - hands on both sides, lower back, have patient breath see if both sides expand equally

Question 10

9. Have a good understanding of the Glasgow Coma Scale

Answer 10

The Glascow Coma Scale provides a score in the range 3-15; patients with scores of 3-8 are usually said to be in a coma. The total score is the sum of the scores in three categories. For adults the scores are as follows:
Eye opening response - spontaneous (4), opens to verbal command (3), opens to pain (2), none (1)
Verbal response - oriented (5), confused but able to answer questions (4), inappropriate responses (3), incomprehensible speech (2), none (1)
Motor response - obeys commands (6), purposeful movement to pain (5), withdraws from pain (4), abnormal flexion (3), rigid response (2), none (1)

Question 11

10. Differentiate between the adventitious lung sounds

Answer 11

Crackles - wet cracking sound (rolling lock of hair by ear), sign of excessive secretions like pneumonia
Wheezing - whistling sound during expiration, sign of narrowed bronchi, indicates asthma
Rhonchi (sonorous wheeze) - loud, low pitched, rumbling coarse sounds, sometimes cleared by coughing
Wheezes (sibilant wheeze) - high-pitched, continuous musical sounds louder on expiration
Pleural friction rub - grating, inflamed pleura, parietal rubbing against visceral

Question 12

11. Know the proper procedure for assessing the abdomen.

Answer 12

Look, listen, feel
Inspect for distention
Auscultate abdomen in 4 quadrants & listen for BM: hypo-bowel (1-5/min), normal (6-30/min), hyper-bowel sounds (>30/min)
Palpate the abdomen: assess for tenderness, masses, and rebound response

Question 13

12. Know the proper technique for doing a bed side neurological assessment

Answer 13

The neurological system is responsible for many functions, including initiation and coordination of movement, reception and perception of sensory stimuli, organization of thought processes, control of speech, and storage of memory.
Measuring a couple of things: overall observation, LOC, affect/mood, speech, able to express thoughts clearly, expressed concerns, equality of pupil size and reaction to light, sensory motor responses (check anterior fontanelles of infant)
Overall observation - grooming, appearance, odor, posture, gait
To assess consciousness ask patient: person, place, time, event, A&O x4
Affect/mood - appropriateness of response / cooperation
Speech - slow, slurred, fast, clear
Able to express thoughts clearly, reality based
To assess motor response: have patient hold your hands and squeeze and compare sides for strength, have patient dorsal/plantar flex again hands and compare strength bilaterally, for child look for symmetry in movement of extremities and assess strength by having them push against hand and grasp finger

Question 14

13. Differentiate between surgical asepsis and medical asepsis

Answer 14

Surgical Asepsis - free of all microorganisms and spores, required for invasive produces (breaking skin barrier)
Medical Asepsis - standard precautions, transmission based precautions, guidelines set up by CDC to provide and help lessen spread of disease

Question 15

14. Know what puts a client at increased risk for a Healthcare Acquired Infection (HAI) ?

Answer 15

Patients with lowered resistance: trauma, pre-existing disease - diabetes or malignancies, very young or very old, inactive, poor nutrition/hydration, invasive procedures - intravenous catheters, bronchoscopy and broad-spectrum antibiotics

Question 16

15. Understand assertiveness communication with other health care professionals

Answer 16

Honest, direct, and appropriate
I statements rather than you
Respect your rights as well as others

Question 17

16. Know the phase of the nurse patient relationship

Answer 17

Pre-introduction/Pre-interaction (Before meeting a patient): Review data available, plan time and location
Introduction/Orientation (When nurse and patient meet, get to know each other): Fairly short; expectations clarified; mutual goals set
Working: Major portion of the interaction (Nurse and patient work together): used to accomplish goals outlined in introduction; feedback from client essential.
Termination (End of relationship): Nurse asks if client has questions; summarizing the topic is another way to indicate closure, transition care.

Question 18

17. Know the purpose of SBAR and what it is all about

Answer 18

Nurse Physician communication
Situation - info of current situation
Background of current situation 
Assessment of current problem
Recommendation that addresses the client’s need

Question 19

18. Know proper communication skills when talking to an older adult

Answer 19

Make sure patient knows that you are talking, face the patient, make sure face/mouth visible, keep communication short and to point
Speak clearly but don’t exaggerate lip movement, check for hearing aids and glasses
Allow time for patient to respond, give patient a chance to ask questions

Question 20

19. Know the different zones of personal space

Answer 20

Intimate space – (0-18in) / personal (18in - 4ft) /social (4-12 ft) / public (12+ ft)
When you should use personal space (from image below):
Intimate: holding crying infant; performing physical assessment; bathing, grooming, dressing, feeding, toileting a patient; changing patient’s dressing
Personal: sitting at patient’s bedside; taking patient’s nursing history; teaching individual patient; exchanging info at change of shift
Social: making rounds with physician, sitting at head of a conference table, teaching a class for patients, conducting a family support group
Public: speaking at a community, testifying at a legislative hearing, lecturing to a class of students

Question 21

20. Know the risks present when a client is on prolonged bed rest

Answer 21

Decreased muscle strength/density, increases blood clot forming, decrease blood volume and increase coagulability, pressure ulcers, constipation, urinary stasis leading to UTI, diminished diaphragm movement leading to impaired secretion clearance
+Orthostatic hypotension- S/S include: dizziness, light-headedness, nausea, tachycardia, pallor and fainting

Question 22

21. Know the relationship between corticosteroids and the inflammatory process

Answer 22

Corticosteroids help to decrease inflammation and reducing the activity of the immune system
+(adrenal) corticosteroids are antiinflammatory and thus cause protein breakdown that will impair immune response
+Corticosteroids will reduce heat production from interference with the immune system and may mask signs of infection (like fever)

Question 23

22. Know the rules concerning the use of a N-95 mask

Answer 23

Properly fits, no facial hair, and do not share or reuse
The mask must have a higher filtration rating than regular surgical masks and be fitted snugly to prevent leakage around the sides.
Respirator blocks 95% of small test particles- used with airborne precautions
+Required by OSHA/CDC for the suspicion/confirmation of TB exposure
+Need to be fitted to mask to ensure a leakage of 10% or less

Question 24

O’Rourke model - 9 steps

Answer 24

Assessment, Analysis, Plan, Implementation, Evaluation, Teach, 6 steps interrelated, Stability of Patient Condition, Care Coordination

Question 25

Rate muscle strength on scale, range of motion

Answer 25

0 to 5 as follows:

0No voluntary contraction
1Slight contractility, no movement
2Full ROM, passive
3Full ROM, active
4Full ROM against gravity, some resistance
5Full ROM against gravity, full resistance (Skills 157)

Question 26

Romberg’s test

Answer 26

Have the patient perform a Romberg’s test by standing with feet together, arms at the sides, both with eyes open and eyes closed. Protect the patient’s safety by standing at the side, observe for swaying. Expect slight swaying of the body in the Romberg’s test. A loss of balance (positive Romberg) causes a patient to fall to the side. Normally he or she does not break the stance. (Potter 559)

Question 27

Edema numbers

Answer 27

2mm: 1+ edema
4mm: 2+ edema
6mm: 3+ edema
8mm: 4+ edema (Perry 139)

Question 28

Mr. Koop is recovering from abdominal surgery 2 days ago for removal of a tumor in his colon and is feeling progressively worse. His temperature was 37° C (98.6° F) 4 hours ago and is now 39.2° C (102.6° F). He is no longer able to tolerate oral fluids and states that he is nauseated. You check his order, which reads, “Acetaminophen 650mg orally for temperature above 38.4° C (101.2° F).” On the basis of the assessment, you believe that, because Mr. Koop is nauseated, he will not be able to tolerate an oral dose of acetaminophen. Thus you decide that you need to call Mr. Koop’s health care provider to see if the medication route can be changed to a rectal suppository. Using SBAR (Situation-Background-Assessment-Recommendation) as your guide, create a report that you will use when calling his health care provider. (Potter 571)

Answer 28

S: Mr. Koop has become progressively worse over the past 4 hours.
B: Mr. Koop had abdominal surgery 2 days ago for removal of a colon tumor. He has an order for acetaminophen 650 mg orally for temperature above 38.5° C.
A: Mr. Koop states that he is nauseated and unable to tolerate fluids right now. His temperature is 39.2° C (102.6° F).
R: Request that the route of acetaminophen be changed from oral to rectal suppository.

Question 29

You are caring for Jane, a 78-year-old who was admitted this morning from home with pneumonia. On assessment you find that Jane has a temperature of 38.7° C (101.6° F) and an oxygen saturation of 88% on 3L of oxygen and is confused and restless. Jane’s daughter reports that Jane is usually alert and oriented, functions well, and lives alone. The health care provider has not seen Jane. Using SBAR (Situation-Background-Assessment-Recommendation), describe how you will communicate with the on-call physician to effectively address your concerns about Jane’s condition. (Potter 316)

Answer 29

S: I am calling about Jane who is having increased respiratory distress.
B: She is a 78 years old and was admitted from home this morning with pneumonia. She was alert and oriented on admission with an O2 saturation of 95% on 2 L of oxygen. She has no history of respiratory problems
A: She has an increased temperature of 101.6° F (38.7° C), her breathing is more labored, and her O2 saturation has dropped to 88% on 3 L of oxygen. She is restless and confused.
R: I think we need to get arterial blood gases (ABGs) and that you need to see her.