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Health Assessment 1 > Exam 2b Questions > Flashcards

Exam 2b Questions Flashcards

1
Q

What is fremitus

A

a palpable vibration, felt when saying 99, during the respiratory assessment

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2
Q

What is a bruit

A

A carotid bruit is a noise caused by turbulent blood flow in the carotid artery. It has been found to be a very good indication of carotid artery stenosis.[1]

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3
Q

What is LOC

A

Level of consciencious

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4
Q

is the state of being free from disease causing microorganisms. is
concerned with eliminating the spread of microorganisms through facility practices. Mainly prevention of spread of disease causing microorganisms from one patient to the next. It is clean but not sterile

A

Medical Asepsis

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5
Q

What are examples of medical Asepsis in facility?

A
  1. handwashing
  2. utilizing gloves, gown and mask as indicated
  3. cleaning equipment
  4. handling linens in ways that prevent germs from spreading
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6
Q

What is surgical asepsis

A

Includes procedures used to eliminate all microorganisms. Also known as sterile technique. Demands the highest level of aseptic technique. ****Contamination occurs with touching of any object that is not sterile!!!!

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7
Q

What are the three categories used in the Glasgow Coma Scale?

A

1) Eye opening response
2) Verbal Response
3) Motor Response

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8
Q

Name the category of the below in the Glasgow Coma Scale and how many points is given for the assessment?

Spontaneous–open with blinking at baseline points

None

A

4 points : Eye opening response

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9
Q

Name the category of the below in the Glasgow Coma Scale and how many points is given for the assessment?
Opens to verbal command, speech, or shout

A

3 points: Eye opening response

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10
Q

Name the category of the below in the Glasgow Coma Scale and how many points is given for the assessment?
Opens to pain, not applied to face

A

2 points Eye opening response

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11
Q

Name the category of the below in the Glasgow Coma Scale and how many points is given for the assessment?
None (will not open eyes under any cirmcustances)

A

1 Point: Eye opening response

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12
Q

Name the category of the below in the Glasgow Coma Scale and how many points is given for the assessment?
Oriented

A

5 points Verbal response

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13
Q

Name the category of the below in the Glasgow Coma Scale and how many points is given for the assessment?
Confused conversation, but able to answer questions

A

4 points Verbal response

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14
Q

Name the category of the below in the Glasgow Coma Scale and how many points is given for the assessment?
Inappropriate responses, words discernible

A

3 Points Verbal response

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15
Q

Name the category of the below in the Glasgow Coma Scale and how many points is given for the assessment?
Incomprehensible speech

A

2 points Verbal response

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16
Q

Name the category of the below in the Glasgow Coma Scale and how many points is given for the assessment?
None (Verbal)

A

1 Point Verbal response

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17
Q

Name the category of the below in the Glasgow Coma Scale and how many points is given for the assessment?
Obeys commands for movement

A

Motor Response

6 points

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18
Q

Name the category of the below in the Glasgow Coma Scale and how many points is given for the assessment?
Purposeful movement to painful stimulus

A

Motor Response

5 points

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19
Q

Name the category of the below in the Glasgow Coma Scale and how many points is given for the assessment?
Withdraws from pain

A

Motor Response

4 points

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20
Q

Name the category of the below in the Glasgow Coma Scale and how many points is given for the assessment?
Abnormal (spastic) flexion, decorticate posture

A

Motor Response

3 points

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21
Q

Name the category of the below in the Glasgow Coma Scale and how many points is given for the assessment?
Extensor (rigid) response, decerebrate posture

A

Motor Response

2 points

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22
Q

Name the category of the below in the Glasgow Coma Scale and how many points is given for the assessment?
None (no movement)

A

Motor Response

1 Point

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23
Q

Is the nursing process linear or dynamic?

A

dynamic

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24
Q

What is step number 7 in the nursing process (Professional Practice Steps)?

A

dynamic integration of 1-6 and has been referred to as critical thinking..Through this dynamic thought process problems are defined and analyzed with an emphasis on questioning information rather than merely accepting it.

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25
Q

What is step number 8 in the nursing process (Professional Practice Steps)?

A

The 8th element or step of this rigorous professional role decision process is the ability to determine the Stability of the Patient Condition

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26
Q

How is stabilility defined

A

the estimate of risk for morbidity and mortality.-it refers to the nursing an medical condition

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27
Q

What is the key professional role in accountability

A

Observing and managing the fluctuation in stability

28
Q

What are the three levels of stability

A

1) Unstable
2) Moderately unstable
3) Moderately stable

***north and south concept: we work to ensure there is progress toward a more stable situation for the medical and nursing condition so as to reduce the risk of morbidity and mortality.

29
Q

What is the 9th step of the O’Rourke Decision making process (Nursing process)

A

The ninth element ties all the steps together. This is an automated slide to review components and that there are some components that you have the option (section 1 and 2 of nurse practice act) of direct and indirect. Example: have a cup – yup this is a cup and I have assessed that. Now does this help me explain the clinical picture (1-7-8). Step 9 says maybe the data is not reliable? (1-789). 2 -7-8-9 Says I have all this data that I have collected, that others have collected, and my comprehensive assessment is that this client is unstable – understanding complexity of the data.
Competence in this step means you have the ability to dynamically integrate elements 7, 8 and 9 with the previous six steps so as to draw a valid and reliable picture of the patient’ condition and the actions required to support the recovery process and provide care.
This step includes the ability to appropriately delegate or assign aspects of care to technical and assistive personnel so that the most appropriate hands deliver the care to the patient
Putting it all together requires an understanding of the professional role as a decision-maker together with clinical practice knowledge.

30
Q

What is the decision making model designed to do?

A

blah

31
Q

A nurse is documenting a patient’s breath sounds. Crackles are heard as:

A

High-pitched, fine sounds at the end of inspiration or expiration

32
Q

When listening to a patient’s posterior chest, the nurse hears loud, coarse rumbling sounds throughout the respiratory cycle. The most appropriate action is to:

A

Ask the patient to cough

33
Q

A 4-month-old infant is admitted for respiratory distress. The finding indicative of respiratory distress is:

A

A soft grunt with each expiration

34
Q

The patient smoked 1.5 packs of cigarettes daily for 10 years and increased to 2 packs a day for 10 years. The patient quit smoking 20 years ago. The nurse should calculate the pack-year history to be:

A

35 pack-years

35
Q

The statement by a patient who smokes that indicates the need for further education regarding prevention and early recognition of lung cancer is:

A

“It’s too late to quit smoking; after 20 years, the damage is done.”

36
Q

The nurse caring for a patient in a cardiac unit is preparing to auscultate the patient’s heart sounds. The nurse correctly asks the patient to:

A

Breathe comfortably and refrain from speaking

37
Q

A patient complaining of chest discomfort is admitted to the unit. The nurse auscultates the patient’s heart sounds and notes a murmur. The characteristics of the murmur that the nurse should assess are the:

A

Intensity and pitch

38
Q

When teaching a student nurse how to auscultate the heart, the nurse correctly explains that the base of the heart is located in the:

A

Upper left portion of the heart

39
Q

A patient is complaining of edema in both feet. The nurse palpates the feet and the imprint of the nurse’s finger remains visible on the foot for 15 seconds. The nurse should determine that the edema is:

A

2+ edema

40
Q

The nurse is examining a patient who has just returned home after an 8-hour plane trip. The patient is complaining of leg pain and his left calf muscle is unilaterally heated, firm, and swollen. The nurse should determine that the patient likely has:

A

DVT

41
Q

The nurse performing a physical examination notices that the skin of the patient’s lower extremities is pale, cool, thin, and shiny. The patient’s nails are thickened and there is little hair growth on the extremities. The nurse should consider that the patient might have

A

Chronic arterial insufficiency

42
Q

The nurse measures the patient’s blood pressures in bilateral extremities while lying, sitting, and standing to check for:

A

Orthostatic hypotension

43
Q

A patient arrives in the emergency department reporting nausea, flulike symptoms, indigestion, back pain, and exhaustion. Initially, the nurse should:

A

Perform only portions of the cardiovascular examination that are absolutely necessary

44
Q

During an assessment of the carotid arteries, the nurse places the bell of a stethoscope over the left carotid artery and hears a blowing or swishing sound. The nurse should suspect that this sound is caused by:

A

A bruit in the carotid artery

45
Q

The nurse assessing a patient’s the muscle strength finds full ROM against gravity with full resistance and correctly assigns a grade of:

A

5

46
Q

When assessing a patient’s LOC, the nurse notes that the previously alert patient will not identify his name or location. The nurse should:

A

Notify the practitioner immediately

47
Q

To assess a patient’s CN V, the nurse should:

A

Apply a light sensation with a cotton ball to symmetric areas of the face

48
Q

When assessing pulses, the nurse cannot palpate a previously palpable dorsalis pedis pulse. The nurse should:

A

Use a Doppler instrument over the pulse site

49
Q

When assessing a 12-year-old female patient, the nurse notices asymmetry of the shoulder and hips. The patient has no complaints of pain. The nurse realizes that this may indicate:

A

Scoliosis

50
Q

When educating a female older adult about preventing bone demineralization, the nurse instructs the patient to:

A

Begin a proper weight-bearing exercise program

51
Q

To perform a Romberg test, the nurse should:

A

Have the patient stand with his or her feet together and arm at sides, both with eyes open and eyes closed (for 20 to 30 seconds), and observe for swaying

52
Q

During orientation, a new nurse is performing an abdominal assessment. Which action indicates that further practice and study is needed?

A

The abdomen is palpated before auscultation is done

53
Q

The nurse concludes that the patient’s abdomen is distended. In order to determine if fluid or air is causing distention, the nurse should palpate for a fluid wave. All of the following statements are true, EXCEPT:

A

Presence of a fluid wave can be detected by using the dominant hand

54
Q

An elderly female patient presents with a history of vomiting and diarrhea. Assessment findings reveal lethargy, decreased skin turgor, a weight loss of 5 lb in 3 days, and a hematocrit of 51%. When obtaining urine for analyses, the nurse observes the urine to be dark amber. Which of the following additional assessment data should the nurse expect to find?

A

Concentrated urine and hyperactive bowel sounds

55
Q

During the assessment of the abdomen, the nurse should:

A

Auscultate for 5 minutes over each quadrant

56
Q

The practitioner should be called immediately if the nurse finds:

A

Vascular sounds over the epigastric region in a 62-year-old man

57
Q

If a patient has an obstructed urinary catheter, the nurse expects to find:

A

A smooth rounded mass at the symphysis pubis

58
Q

A patient with hepatitis could be expected to have an enlarged liver. This can be best palpated in the:

A

Right upper quadrant

59
Q

The most pronounced change in GI function in an older adult is constipation caused by:

A

Decreased peristalsis

60
Q

The nurse is preparing to admit a patient with pulmonary TB and correctly plans to implement:

A

Standard precautions and airborne precautions

61
Q

When preparing to enter the room of a patient who has Clostridium difficile infection, the nurse should follow contact precautions, which include the use of:

A

Gloves and gowns

62
Q

After assessing a patient who requires isolation precautions, the nurse should clean the stethoscope with:

A

70% alcohol

63
Q

When leaving a patient’s room and preparing to remove isolation garments, the appropriate order of PPE removal to prevent cross contamination is:

A

Gloves, eyewear, gown, mask

64
Q

It is important that the nurse understands that standard precautions are to be used for all patients. This includes wearing gloves during nursing care when:

A

Touching blood, body fluids, or mucous membranes

65
Q

Is tuberculosis airborne? What are the precautions? What are other airborne conditions?

A

Yes, put patient in private negative ventilation room and N95 mask. measles (rubeola),
chicken pox (varicella zoster)
& tuberculosis

66
Q

Which diseases are droplet and require separate room for patient?

A

diphtheria, pertussis,
mumps, rubella,
pneumonic plague
Patient must be put in private room, surgical mask

67
Q

Which diseases are contact diseases? What are the precautions?

A

Presence of stool incontinence (may include patients with norovirus, rotavirus, or Clostridium difficile), draining wounds, uncontrolled secretions, pressure ulcers, or presence of ostomy tubes and/or bags draining body fluids
Presence of generalized rash or exanthems

Precautions: put in private room, wear gown and gloves (PPE-personal protective equipment), must wash hand before and after PPE preferably antimicrobial soap

More diseases: Hepatitis A, Shigella,
herpes simplex virus,
impetigo MRSA & VRE

Health Assessment 1 (3 decks)

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