Final Exam Study Guide Flashcards
when palpating pulses, what system is being evaluated?
cardiovascular
when moving a patient with a BMI of 32, what tool should you use?
hoyer lift
which patient should you see first?
- an older client with decreased upper extremity muscle loss
- one with stiff fingers and joints in the morning
- someone who slumps forward when standing
- a patient who can’t grip one of their hands
a patient who can’t grip with one hand
- could be a stroke finding
what stage pressure ulcer is broken skin?
stage 2
what stage pressure ulcer is when the sub-cutaneous is exposed?
stage 3
what stage pressure ulcer is when the bone is exposed?
stage 4
where can you hear vesicular lung sounds?
lung fields
- mostly what we listen to
where can you hear bronchovesicular lung sounds?
near sternal notch
where can you hear bronchial lung sounds?
up by clavicle
how do you classify a patient who has a blood pressure of 138/88?
stage 1
how do you classify a patient who has a blood pressure of 142/96?
stage 2
how do you know if a patient who has cognitive impairment is in pain?
- nonverbal signs
- wong-baker pain scale
after giving pain medications and coming back 30 min later to see how a patient is doing, falls under what part of the nursing process?
evaluation
an older male experiencing nocturia and unable to fully empty bladder likely has what condition?
BPH
what is phimosis?
can’t retract the foreskin
which finding on an abdominal assessment is abnormal?
- soft
- active bowel sound
- convex shape
- ecchymosis
- convex shape
- ecchymosis
right after you put a wound dressing on a patient’s upper arm, a CNA takes BP on that same arm,
is that ok?
no
- needs to be done on a healthy arm
- cuff 80% arm circumference and 40% of width
- not on same side as mastectomy, PICC, bandage, etc.
a testicle feels rubber y and smooth,
is that normal?
yes
- do not need to go to the doctor
which part of the stethoscope is used to listen for S1, S2 heart sounds?
diaphragm
which joints can perform rotation?
- neck
- wrist
- thumb
- jaw
- finger
- neck
- wrist
- thumb
which sinus is located under the cheekbones?
maxillary
a patient with rectal itching and blood in their stool likely has what condition?
hemorrhoids
who is at the greatest risk for skin breakdown?
- patient with a fracture clavicle
- patient with a broken arm
- patient with femur fracture
- patient with hip fracture
femur or hip fracture
- differentiate based on age
- older client less likely to move as much and at higher risk for skin breakdown
what are important points for proper body mechanics?
- push don’t pull
- bend at the knee
- use legs not back to lift
- wide stance
- raise bed to working height
- carry object close to the body
which findings are subject?
- dizziness
- skin color
- skin turgor
- pain
- vitals
- lab results
- dizziness
- pain
which findings are objective?
- dizziness
- skin color
- skin turgor
- pain
- vitals
- lab results
- skin color
- skin turgor
- vitals
- lab results
how do you assess CN X (vagus)?
- ask the patient to swallow and say ahh
- check the gag reflex
how do you assess CN XI (spinal accessory)?
- ask patient to shrug shoulders against resistance
how do you assess CN XII (hypoglossal)?
- stick out tongue
how do you assess CN VII (facial)?
- have client puff out their cheeks
- make faces
- test taste on anterior tongue
how do you assess CN VIII?
- Romberg test
- Whisper test
how can you increase safety for a patient with impairment of CN II?
vision
- adequate lighting
- make clear path
- no cords
- keep glasses close by
- do not put up all 4 bedrails
which cranial nerves are responsible for EOM?
III
IV
VI
where can you assess a client with dark skin for cyanosis?
- MM
- conjunctiva
- palms
what is circumoral cyanosis?
- purple/blue color around the mouth
- indicates respiratory distress and needs to be addressed immediately
how do you evaluate the effectiveness of respiratory medicatiions?
listen to lungs shortly after administering the treatment
what should you do when you palpate an irregular pulse?
use stethoscope and listen to apical pulse for 60 seconds
how do you assess the carotid?
- palpate unilaterally (never bilaterally)
- auscultate using the bell of the stethoscope
where is the mitral valve located?
between left aria and ventricle
what are the auscultation points for a cardiac assessment?
- aortic: 2nd ICS R of the sternum
- pulmonic: 2nd ICS L of the sternum
- erbs point: 3rd ICS L of the sternum
- tricuspid: 4th ICS L of the sternum
- mitral (apical): 5th ICS midclavicular L of the sternum
when should you use standard precautions?
- when obtaining vitals
- palpating sinuses
- shining penlight in their eyes
- palpating the tongue/gums
palpating tongue/mouth
- contact with body fluids
what equipment is required to assess for PERRLA?
- penlight
what are crackles and what causes them?
- caused by air passing through fluid
- sounds like bubbling/crackling like rice crispy
- soft, high-pitched, very brief
- usually on inspiration
- pulmonary edema, atelectasis, fibrosis, and pneumonia
what are wheezes and what causes them?
- narrowing of airway passages by spasm, inflammation, mucus, or tumor
- if hearing, ask them to do a few deep breaths and cough
- high-pitched musical, whistling, or squeaking sounds
- MAY CLEAR WITH COUGHING
- can be heard on inspiration or expiration
what tasks can AP perform?
- nursing process
- ADL car
- document assessment
- evaluate effectiveness of an intervention such as oxygen
ADL care
- cannot perform the other tasks
which intervention for dyspnea should be performed first?
- call the doctor
- raise the head of the bed
- put on oxygen
- get an ABG
- raise the head of the bed first
what is the term used for yellow sclera?
jaundice
what is erythema?
red in color
what is pallor?
white/pale in color
what is cyanosis?
blue in color
what should you do before inserting the otoscope into an adult client’s ear?
pull pinna UP and BACK
which patient should you see first?
- patient with HR 90
- patient with temperature 99.2
- patient with RR 30 bpm
patient with RR 30 bpm
what is included in a cardiovascular assessment?
- focuses history: chest pain, edema, palpitations, dyspnea, cough, syncope, fatigue
- general survey/inspection: signs of JVD
- palpate pulses: carotid unilaterally, radial and pedal bilaterally
- palpate chest for vibrations
- percussion
- auscultate: carotids for bruit with bell, use diaphragm for 5 pulse points - apical for 60 seconds
what are signs of right sided heart failure?
- JVD
- lower limb edema
- ascites
- sudden weight gain
- fatigue
- hepatosplenomegaly
anorexia
what are signs of left heart failure?
- pulmonary congestion
- crackles
- cough
- wheezes
- blood-tinges sputum
- dyspnea
- tachypnea
- cyanosis
- fatigue
how long should you auscultate the lungs at each point?
one full inspiration and expiration
- move from right to left to compare sounds
what are components of general survey?
- general health state and any obvious physical characteristics
- overall first impression about physical appearance
- body structure
- hygiene
- mobility and behavior
- not vital signs
what are the ABCDE signs of melanoma when considering a suspicious skin change?
A = asymmetry
B = irregular borders/bleeding
C = color change/multicolored
D = diameter greater than 0.5 cm
E = enlarging in size
in addition:
- individuals may report a change in size
- the development of itching
- burning
- bleeding
- a new-pigmented lesion
- any one of these signs raises the suggestion of melanoma and warrants immediate referral
what are expected changes in the older adult?
- hard, thick nails
- loss muscle tone
- BP higher
- decreased motility
- decreased vision
- sky dryness
- thin and translucent skin
non-blanchable erythema of intact skin
stage 1 pressure ulcer
partial thickness skin loss with exposed dermis
stage 2 pressure ulcer
full-thickness skin loss visible adipose tissue with possible granulation tissue
stage 3 pressure ulcer
full-thickness skin and tissue loss with exposed bone muscle or ligaments
stage 4 pressure ulcer
normal BP
< 120/80
elevated BP
120-129/<80
stage 1 hypertension
130-139/80-89
stage 2 hypertension
> or equal to 140/90
what is referred pain?
originates in one location but can be felt in others
heart attack -> pain in jaw, back, shoulders
what questions would you ask when assessing a patient with a headache?
- when did it start
- where is it located specifically
- have you taken anything and did it help
- anything make it worse, light/sound
- don’t need family history
what are the stages of the nursing process? (ADPIE)
A = assessment
D = diagnosis
P = planning
I = implementation
E = evaluation
what is BPH?
benign prostatic hypertrophy
signs/symptoms of BPH?
- common in aging males
- nocturia
- increased urgency and frequency
- inability to completely empty the bladder
what are normal findings of an abdominal assessment?
- abdomen flat
- no vibrations or bruit over the abdominal aorta
- normal bowel sounds every 5 - 15 seconds in all 4 quadrants
- tympany with dullness over organs on percussion
- soft with no tenderness or masses on palpation
what should you do if the client is not fluent in english?
- use a trained interpreter
- speak directly to the client
- avoid medical jargon
- use interpreter for entire assessment
- legally cannot use the patient’s children to translate
what are causes of high blood pressure?
- high salt diet
- stress
what are important points about a self-testicular exam?
- testicles should feel rubbery and smooth
- if client notices a firm, painless lump, hard area, or enlarged testicle, they should call their provider
what are important points about a self- breast exam?
- performing exam 4-7 days after cycle starts
- place hands on hips and look in mirror
- then palpate entire breast tissue axilla to sternum
- use 3 middle fingers
what are the 4 main functions of skin?
- temp regulation: skin allows heat dissipation through sweat glands and heat storage with SQ tissue
- protection: minimizes injury, no opening for infection
- first line of defense: when skin integrity is impaired client is at risk for pathogens entering
how do you palpate the frontal sinuses?
press firmly upward just under the eyebrows
who is likely to develop lordosis?
pregnant women
what part of orientation is the first to go in older adults?
time
how do you perform the Romberg test and what is it evaluating?
- client to stand with their feel together
- eyes closed
- arms resting at their side while nurse observes for swaying or falls
- tests balance
what is abduction?
movement away from the body
what is adduction?
movement towards the body
what is fidelity?
fulfill a promise to the patient
what is beneficence?
provide best quality care to patient
what is non-maleficence?
commitment to do no harm
what is autonomy?
nurse who acts within scope of practice
what are some causes of tachycardia?
- fever
- medication
- changing position
- hyperthyroidism
- not marathon runner
what is scoliosis?
S-shaped lateral curvature of the spine
describe wound drainage SERIOUS exudate?
- straw colored
- watery consistency: contains little cellular matter
describe wound drainage sanguineous?
bloody drainage
describe wound drainage serosanguineous?
- mix of bloody and straw-colored fluid
- most common in fresh wounds
describe wound drainage purulent?
- yellow
- contains pus-infection
what are you assessing when percussing the CVA?
- kidney infection/tenderness
which part of the hand will the nurse use to palpate the skin temperature?
dorsal
which part of the hand will the nurse use to palpate skin moisture?
palmar
when testing the brachioradialis reflex, the nurse should expect which response?
pronation of the forearm and flexion of the elbow
