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NU 305 > NU 305 Final Exam > Flashcards

NU 305 Final Exam Flashcards

1
Q

What is a focused assessment and when do we use it?

A

occurs in all settings, smaller​
in scope but increased depth for​
specific issue(s). ​

Do this exam after treatments performed or in an outpatient setting​

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2
Q

What is a comprehensive assessment and when do we use it?

A

complete health history and physical assessment performed​

Annually for outpatients (ex: any type of physical)​

When entering a long term care/hospital facility​

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3
Q

What is subjective data?

A

All information comes directly from the patients mouth​

The nurse should ask open ended questions to ensure they get as much information as possible​

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4
Q

What is objective data?

A

This is something measurable​

Something the nurse observes from the client ​

Assess vital signs ​

Turgor ​

Temperature ​

Color ​

Moister ​

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5
Q

How do you state a chief complaint?

A

In the clients own words

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6
Q

What is a review of systems?

A

The review of systems is a series of questions about all body systems.​

Ask the patient about any symptoms that they have.​

Use common language when asking the patient questions. ​

These questions can all be found on page 38, box 2.3​

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7
Q

What is the Pre-Interaction Phase?

A

What we do before we meet our patient. We should have received a report, looked at their chart, and have an idea about what is going on before going into the patient’s room.

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8
Q

What is the Beginning Phase?

A

Introduce yourself and give the patient your title. Want to ask the patient what they would like to be called. Secured our environment for privacy.​

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9
Q

What is the working phase?

A

Collecting data. Close and Open-ended questions- open ended questions are for when we want our patient to elaborate. Close ended questions are questions that are yes, and no. Avoid questions like “Why?” We want to try to document as we go, but also maintain therapeutic communication with patients.​

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10
Q

What is the closing phase?

A

Ask if there is anything else from the patient. Now is where we summarize everything, and what we are going to do next in their plan of care.

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11
Q

What is an interpretor?

A

The interpreter role is to facilitate communication between two or more people who use different languages, being either spoken or written​

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12
Q

What are some non-verbal communication techniques?

A

Physical Appearance,
Facial Expressions,
Posture,
Position towards the patient,
Gestures,
Eye Contact,
Tone of Voice,
Use of Touch ​

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13
Q

What are some verbal communication techniques?

A

Restatement, Reflection, Elaboration, Silence, Focusing, Clarification, Summarizing​

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14
Q

What are normal inspection/palpation findings for the heart and neck vessels?

A

Inspection/Palpation: precordium (chest wall), locate the PMI and palpate (5th ICS MCL) (pulse should be clear to find)​

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15
Q

What are some modifiable CV risk factors?

A

Smoking, High Cholesterol, High BP, Overweight/obesity, exercise​

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16
Q

What are some non-modifiable CV risk factors?

A

Age, family history, diabetes diagnosis​

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17
Q

What is systole?

A

Ventricles contract and eject blood to the lungs and body. The beginning of systole correlates with the pulse blood is being circulated. During systole, the closed mitral and tricuspid valves present regurgitation (backflow) of blood into the atria. The aortic and pulmonic valves are open while blood moves forward. ​

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18
Q

What is distole?

A

Diastole is twice as long as systole to allow time for the ventricles to fill. As the heart rate increases, however, length of diastole shortens and becomes approximately equal to systole. The coronary arteries are also perfused during diastole. During diastole, the aortic and pulmonic valves are closed to prevent regurgitation of blood from the aorta and pulmonary artery into the ventricles. The open mitral and tricuspid valves allow filling from the atria to the ventricles. The three phases of ventricular filling are early filling, slow passive filling, and, finally, arterial systole, also called “atrial kick.” An additional 5% to 30% of blood volume is squeezed into the ventricles during the atrial kick.​

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19
Q

What are some top nursing diagnoses for the CV system?

A

Decreased Cardiac Output-​

Risk for decreased Cardiac Tissue Perfusion-​

Excess Fluid volume-​

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20
Q

Describe a carotid evaluation

A

The Contour of the carotid artery is smooth and should be graded as 2+ bilaterally​

Avoid palpating bilaterally as it could block blood flow to your patients brain​

Use the bell of your stethoscope to auscultate​

Note signs of bruits which is a swooshing sound when you are listening to the artery​

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21
Q

What are the sounds and characteristics of a cardiac murmur?

A

Characterized by a blowing or swooshing sound due to turbulent blood flow through the heart or great vessels or by Increased velocity of blood flow across a valve.​

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22
Q

What are normal findings of the peripheral vascular system?

A

Extremities without prominent venous pattern.​

Nail beds are pink without clubbing, Capillary refill is <3 seconds.​

Jugular vein without distention​

Arms and hands are warm and equal in temperature.​

Texture is firm, even, and elastic. ​

No edema is found​

Bilateral pulses equal in extremities​

Grade of pulses are 2+​

Skin color normal for ethnicity​

No sores or lesions ​

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23
Q

What are some nursing diagnoses for the peripheral vascular system?

A

(add this later)

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24
Q

How do you grade a pulse?

A

0: Pulse is nonpalpable or absent ​

1+: Weak and thready ​

2+: Normal pulse, expected ​

3+: Full, increased pulse ​

4+: Bounding pulse ​

(Document a normal pulse as 2+/4)​

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25
Q

What are the different pulse sites?

A

Pulse sites: temporal, carotid, apical, brachial, radial, ,femoral, popliteal, dorsalis pedis, and posterior tibial

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26
Q

What are s/s of decreased blood flow?

A

Skin is cool to touch, thin, dry, and scaly, thick toenails and no hair​

-Pulses are unequal, weak, or absent​

-Intermittent claudication occurs​

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27
Q

What are abnormal inspection findings of the peripheral vascular system?

A

Cyanosis, clubbing of the nails, capillary refill more than 3 seconds.​

Abnormal hair distribution​

Lesions and sores​

Edema​

Spider veins and varicose veins​

Pain, polar, paresthesia, paralysis, pallor, pulselessness, perfusion

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28
Q

What are abnormal findings for peripheral vascular palpation?

A

When assessing skin temperature; decreased arterial blood supply may lead to changes on the lower extremities such as cool skin temperature. Coolness of an extremity may indicate arterial occlusion. Assess quickly for the other seven Ps (see Box 18.2) and determine whether condition constitutes an emergency.​

When assessing skin turgor; rough or dry texture and poor turgor may be noted with dehydration. Lymphedema is likely when Stemmer sign is present. Inability to pinch skin on the dorsum of the hand or foot of the affected extremity during examination is a positive Stemmer sign.​

Evaluate any pulse that cannot be palpated with the Doppler stethoscope for an arterial signal. If pulselessness persists, quickly evaluate the remaining of the seven Ps to determine whether this problem constitutes an emergency ​

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29
Q

What are some skins alterations common for African Americans?

A

keloid formation, traction alopecia, pseudofolliculitis, ashy dermatitis, increased melasma in pregnancy leading to Mongolian Spots​

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30
Q

What are some skin alterations common for Asians?

A

less body and facial hair​

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31
Q

What are some skin alterations common for Arabics and Indians?

A

henna tattoos, ​

-arabic lesions: Mongolian Spots, congenital nevi (moles) ​

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32
Q

Where are pressure sores most common?

A

heels, elbows, the back of the head and the tailbone

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33
Q

Describe a stage I pressure ulcer

A

intact skin with nonblanchable erythema​

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34
Q

Describe a stage II pressure ulcer

A

partial thickness loss of skin, no Escher or slough​. Dermis exposed

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35
Q

Describe a stage III pressure ulcer

A

Full thickness loss of skin, potential for Eschar and slough, no bones visible​. Adipose exposed

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36
Q

Describe a stage IV pressure ulcer

A

full thickness, bones, muscles, or tendons visible​

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37
Q

Describe an unstageable pressure ulcer

A

wound bed is not visible due to slough and eschar​

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38
Q

What are some normal inspection findings for the thorax/lungs?

A

2:1 AP ratio, color, shape, and condition of patients fingernails, unlabored respiration rate​

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39
Q

What are some normal palpation findings for the thorax/lungs?

A

Test for symmetrical chest expansion from the posterior side, tactile fremitus symmetrical, trachea placement ​

40
Q

What are some normal percussion findings for the thorax/lungs?

A

lungs resonant

41
Q

What are some normal auscultation findings for the thorax/lungs?

A

Listen with diaphragm of the stethoscope posterior, anterior, and lateral chest wall. 4 anterior sites, 6 posterior sites, and 2 lateral sites. Hold for full breath. Note any abnormal breath sounds or adventitious sounds​

42
Q

What are some abnormal inspection findings of the thorax/lungs?

A

Poor fingernail shape, color, and condition (blue color is the most urgent). Use of external intercostal muscles indicate the client is having a hard time with respiration.

43
Q

What are some abnormal palpation findings of the thorax/lungs?

A

Decreased fremitus is a foreign body, large mucous plug in the bronchus, pleural effusion, pulmonary fibrosis, solid tumor or pneumothorax causing restricted air movement through the lung. Increased Fremitus is consolidation with a localized pneumonia. While assessing for chest expansion, abnormal findings would show unequal chest expansion indicating pneumonia, pneumothorax, or thoracic trauma.​

44
Q

What is wheezing?

A

is when there is a whistling sound while breathing. Common in asthma, COPD, bronchitis, colds, and more.​

45
Q

What is stridor?

A

is high-pitched crowing that can be heard without a scope; EMERGENT; due to airway obstruction ​

46
Q

What are rales/crackles?

A

intermittent, crackling, popping, may be fine and high, or course and low pitched. DOES NOT CLEAR WITH COUGH. Can be caused by fluid, inflammation, or consolidation in the alveoli ​

47
Q

What is ronchi?

A

continuous, low pitched, snoring sounds. Result from secretions moving through the airways. Louder on exhalation than inhalation. Cleared with cough. ​

48
Q

What are abnormal inspection findings for the abdomen?

A

Masses​

Visible abdominal aortic pulsations​

Skin color jaundiced; stretch marks

49
Q

What are abnormal percussion findings for the abdomen?

A

Pain, dullness over mass, or fluid. CVA tenderness

50
Q

What are some abnormal auscultation findings for the abdomen?

A

Absent bowel sounds in one or all of the four quadrants​

Bruit over the vasculature of the abdomen​

51
Q

What are some abnormal palpation findings for the abdomen?

A

Pain or tenderness in one or all of the four quadrants​

Tenderness, enlarged organs upon deep palpation​

Patient guarding upon deep palpation​

Palpable masses​

Fluid wave​

52
Q

What are some normal inspection findings for the abdomen?

A

shape contour and movement (documentation ): Abdomen flat and symmetrical. No scars, striae, or varicosity. Skin even-toned. Umbilicus midline and inverted. No hernias noted. No distension or visible pulsation.​

53
Q

What are some normal urine findings?

A

urine clear and light yellow.

54
Q

What are normal emesis findings?

A

No emesis present

55
Q

What are normal stool findings?

A

Stool is soft, light brown and formed​

56
Q

What are normal auscultation findings for the abdomen?

A

Bowel sounds are present in all four quadrants​
No bruit, venous hum, friction rub noted

57
Q

What are some normal percussion findings for the abdomen?

A

Tympany over most of the abd. Dullness over the liver in the RUQ. No pain with kidney percussion.​

58
Q

How would you document normal findings for the abdomen?

A

“Abdomen tympanic. No dullness over the liver in the RUQ and hallow tympanic notes in the LUQ over gastric bubble. Over most of the abdomen, tympanic sounds are heard. No CVA tenderness. Spleen is dull. Bladder is non palpable.”​

59
Q

What are normal palpation findings of the abdomen?

A

Light palpation of all 4 quadrants: No pain ​
Deep palpation of all 4 quadrants : Abd without mass or tenderness ​

Spleen: is not palpable​

Bladder scanning Normal < 600 ml before voiding. < 200ml after ​

Aorta: pulsation palpable. Measures 2 cm.​

Fluid wave: No fluid wave ​

60
Q

How do you perform a Blumberg test?

A

Assess for Blumberg sign or rebound tenderness to check for peritonitis. In a site away from the painful area, push down your hand at a 90-degree angle slowly and deeply, then lift up quickly. A negative and normal response is no pain when the pressure is released.​

61
Q

What does a Blumberg test assess for?

A

Peritonitis

62
Q

How do you assess for Murphy’s sign?

A

is the assessment to check for inflammation in the gallbladder. Holding your fingers beneath the liver border, apply mild pressure and ask the patient to breathe deeply. Normally, no pain occurs and the test result is negative.​

63
Q

What does the Murphy test assess for?

A

Inflammation in the gallbladder.

64
Q

How do you perform an obturator test?

A

Flex the patient’s right thigh at the hip with the knee bent and rotate the leg internally at the hip, which stretches the internal obturator muscle. RLQ pain constitutes a positive obturator sign, suggesting an inflamed appendix or peritoneal inflammation.​

65
Q

What does the obturator test indicate?

A

Appencitis

66
Q

What are some top nursing diagnoses for the musculoskeletal system?

A

Immobility
Fall risk
Spinal cord injury
Congenital hip dysplasia
Total joint replacement
injury
Osteoarthritis
Osteoporosis
Rheumatoid arthritis

67
Q

What are normal inspection findings for the neuro system?

A

patient is oriented x4, speech is clear fluent and articulate, PEARLA, movements smooth and symmetrical, ​

68
Q

What are normal palpation findings for neuro?

A

relaxed muscle shows appropriate muscular tension, Good muscle bulk and tone, No spasticity or rigidity, muscle strength 4-5+, patient walks smoothly without swaying, Gait steady, Romberg test- Patient maintains position without opening the eyes, well-coordinated movements, Sensation intact and symmetrical (and identify the area of the body), Sensation intact and symmetrical (and identify the area of the body), patient correctly identifies light touch, pain sensation intact, Temperature sensation intact, Intact motion and position sense, DTRs are 2+ bilaterally without clonus, plantar response- toes flex​

69
Q

How to we grade reflexes?

A

4+—Very brisk, hyperactive with clonus​

3+—Brisker than average​

2+—Average, normal​

1+—Diminished, low normal​

0—No response​

70
Q

Where do we test deep tendon reflexes?

A

biceps, triceps, brachioradialis, patellar, and Achilles

71
Q

Describe an alert patient

A

Pt awake, alert, and oriented to time, place, and person; well groomed; makes eye contact; speech clear and appropriate; feeding self without difficulty.​

72
Q

Describe a confused patient

A

Pt. stated correct name, but disoriented to time and place; attempting to get out of bed and stated, I’m at the supermarket. I need to catch the bus because I’m going to the movies.’‘​

73
Q

Describe a lethargic patient

A

slowed or sluggish speech, mental processes, or motor activities: Pt. awakens to her name; oriented to time, place, and person; will not initiate a conversation; answers questions slowly and then falls asleep.​

74
Q

Describe a patient experiencing obtundation

A

Pt. aroused by gently shaking her arm and repeatedly calling her name; responds with one-word answers; follows simple commands; disoriented to time and place.​

75
Q

Describe a patient experiencing stupor?

A

Unable to arouse pt. via verbal stimulation; required noxious stimulation (nail bed pressure). Confusion noted when aroused; incomprehensible sounds; purposeful response to painful stimuli.​

76
Q

Describe a comatose patient

A

Unable to arouse pt.; no response to verbal stimulation; no response to noxious stimulation; no spontaneous movements noted.​

77
Q

What is cranial nerve I?

A

Olfactory (smell)

78
Q

What is cranial nerve II?

A

Optic (vision)

79
Q

What is cranial nerve III?

A

Oculomotor eye movement–upward, medial, downward, up & in

80
Q

What is cranial nerve IV?

A

trochlear eye movement– superior oblique (down & in)​

81
Q

What is cranial nerve V?

A

trigeminal sensory of face and mouth; helps chew​

82
Q

What is cranial nerve VI?

A

abducens eye movement—look side to side​

83
Q

What is cranial nerve VII?

A

face
facial expression; lacrimal & salivary glands (2/3 of tongue)​

84
Q

What is cranial nerve VIII?

A

auditory/vestibular
Acoustic: equilibrium & hearing​

85
Q

What is cranial nerve IX

A

Glossopharyngeal: swallowing; speech; parotid salivary gland (posterior 1/3 of tongue)​

86
Q

What is cranial nerve X?

A

Vagas Nerve: autonomic; breathing, heart beating, digesting food​

87
Q

What is cranial nerve XI?

A

Accessory: sternocleidomastoid & trapezius (neck & shoulder movement)​

88
Q

What is cranial nerve XII?

A

Hypoglossal: tongue movement ​

89
Q

What is dizziness?

A

presents a range of symptoms such as light-headedness, faintness, wooziness, unsteadiness, off-balance, and weakness. ​

90
Q

What causes dizziness?

A

Can be caused by impairment, low glucose levels, dehydration, drugs, anxiety, concussion, etc. ​

91
Q

What is vertigo?

A

a type of dizziness that presents as though your surroundings are spinning around you or you are spinning in your surroundings.

92
Q

What causes vertigo?

What diseases etc.

A

Can be caused by MS, Parkinsons, cerebellar infarction or ischemia, benign or malignant neoplasms, and arteriovenous malformation of brain vessels. ​

     - Usually associated with inner ear
93
Q

How do you perform a corneal light reflex?

A

-Instruct the patient to stare straight ahead at the bridge of your nose. Stand in front of the patient and shine a penlight at the bridge of the patient’s nose. Note where the light reflects on the cornea of each eye​

-Improper alignment and appear as asymmetric reflections. Document unexpected findings using the face of the clock as a guide.

94
Q

How to perform a cardinal gaze test?

A

Further testing of the extraocular muscles assesses for symmetrical movements of the eyes in all nine cardinal fields of gaze. Instruct the patient to hold the head steady and to follow the movement of your finger or pen with the eyes. Hold your finger or pen approximately 30–35 cm (12–14 in.) from the patient’s face. Move slowly through positions 2 through 9, stopping momentarily in each, and then back to center (Fig. 13.15). Proceed clockwise.​

-Document a deficit by noting in which field an abnormality is found. Mild nystagmus at the extreme lateral angles is normal; in any other position it is not. See Table 13.5.​

95
Q

How can you prevent osteoperosis?

A

Maintaining an active lifestyle and healthy weight. 30 min weight bearing exercise 3 times per week
* Protection of joints while performing simple tasks
* Daily recommended amount of calcium and vitamin D. Limit caffeine
* Discuss risks of osteoporosis with provider
* Bone density test and meds

96
Q

What are some top nursing disagnoses for the nuero system?

A

impaired verbal communication
Acute confusion
Imaired memory
Unilateral neglect
Risk for aspiration
Decreased intracranial adaptive capacity
Riskfor impaired nervous system

97
Q

What are some nursing diagnoses for the peripheral vascular system?

A

Ineffective peripheral tissue perfusion
Risk for peripheral neurovascular dysfunction
Activity intolerence

NU 305 (5 decks)

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