NURS 100 Test 1

Question 1

A nurse is completing a clients history and physical examination. Which of the following should the nurse consider subjective data?

A) BP
B) Cyanosis
C) Nausea
D) Rash

Answer 1

C) Nausea

Question 2

Normal BP

Answer 2

Systolic: less than 120
Diastolic: less than 80

Question 3

elevated BP

Answer 3

Systolic: 120-129
Diastolic: less than 80

Question 4

High BP (hypertension) Stage 1

Answer 4

Systolic: 130-139
Diastolic: 80-89

Question 5

High BP (hypertension) Stage 2

Answer 5

Systolic: 140 or higher
Diastolic: 90 or higher

Question 6

Hypertensive crisis

Answer 6

Systolic: higher than 180
Diastolic: higher than 120

Question 7

what is the purpose got obtaining a physical assessment

Answer 7

1) identifies patient needs
2) to establish a database about the patients health concerns or illness
3) determine the ability to manage health care needs

Question 8

Pain assessment (PQRST)

Answer 8

P: palliative/provokes: what makes the pain lessen or worse
Q: Quality: sharp, stabbing, throbbing, aching
R: Region/Radiate: where is the pain and does it spread
S: Severity: scale 0-10
T: timing: when did the pain start

Question 9

subjective data

Answer 9

-apparent only to person affected
-what the client states
-symptoms

Question 10

Objective Data

Answer 10

-detectable by the observer/ nurse
-signs
-see, hear, smell, feel

Question 11

examination sequence

Answer 11

1) inspection
2) palpation
3) percussion
4) auscultation

Question 12

abdomen inspection

Answer 12

1) inspection
2) auscultation
3) percussion
4) palpation

Question 13

Normal assessment findings in an adult

Answer 13

-A&O x4
-temp: 36-38C (96.8-100.4F)
-pulse: 60-100 bpm @rest
-respiration: 12-20/min
-oxygenation: 95-100%

Question 14

Data collection methods

Answer 14

1) Observing
2) Interviewing
3) Examining
4) Collaboration

Question 15

physical assessment

Answer 15

1) general survey
2) measurements
3) Head-to-toe assessment

Question 16

systematic approach to physical assessment

Answer 16

1) general survey/ psychosocial
2) integumentary
3) neuro/muscular
4)EENT
5)cardiovascular
6) respiratory
7) gastrointestinal (GI)
8) genitourinary (GI)
9) misc. (dressings, IV, drains)

Question 17

General patient survey

Answer 17

-general body structure
-facial expression and affect
-are they in distress or pain
-speech
-hygiene, grooming, and dress
-posture and mobility
-equipment
-odors

Question 18

PERRL

Answer 18

-Equality
-Shape
-Reactive to light
-Direct/consensual

Question 19

paresis

Answer 19

weakness; slight incomplete paralysis

Question 20

hemiparesis

Answer 20

weak on one side of the body

Question 21

plegia

Answer 21

no movement; paralysis

Question 22

hemiplegia

Answer 22

paralysis on one side of the body

Question 23

Muscle strength grading

Answer 23

0: no contraction
1: flicker of contraction
2: active movement; can’t resist gravity y
3: active movement against gravity
4: active movement against resistance
5: normal strength

Question 24

Strength and quality of pulse

Answer 24

0: absent, not palpable
+1: diminished, barely palpable
+2: easily palpable, normal pulse
+3: bounding, cannot be obliterated

Question 25

Measuring pitting edema

Answer 25

0+: no pitting
1+: mild pitting, 2mm deep and disappears rapidly
2+: moderate pitting, 4mm deep and last 10-15 seconds
3+ moderately severe, 6mm deep, may last more than a min.
4+: severe pitting, 8mm deep can last more than 2 min.

Question 25

Measuring pitting edema

Answer 25

0+: no pitting
1+: mild pitting, 2mm deep and disappears rapidly
2+: moderate pitting, 4mm deep and last 10-15 seconds
3+ moderately severe, 6mm deep, may last more than a min.
4+: severe pitting, 8mm deep can last more than 2 min.

Question 26

COCA

Answer 26

Color
Odor
Consistency
Amount

Question 27

5 steps of nursing process

Answer 27

1) assessment
2) nursing diagnosis/ analysis
3) planning
4) implementation
5) evaluation

Question 28

how do you get assessment data?

Answer 28

observe, physical assessment, nursing interview

Question 29

3 part nursing diagnosis

Answer 29

1) diagnosis
2) r/t and secondary to
3) defining characteristics AEB

Question 30

medical diagnosis

Answer 30

identification of disease condition based on specific evaluation of signs and symptoms
(focus is on a disease process)

Question 31

nursing diagnosis

Answer 31

a clinical judgement about the patients response to an actual or health problem
(focus on the human response to the health problem)

Question 32

Nursing Diagnosis errors

Answer 32

1) errors in data collection
2) errors in interpretation of data
3) errors in data clustering

Question 33

intervention types

Answer 33

1) independent
2) dependent
3) collaborative

Question 34

independent intervention

Answer 34

-nurse initiated
-does not require direction or an order
-acting independently behalf of the patient

Question 35

Dependent interventions

Answer 35

-provider initiated
-requires an order from a physician based on response to treat a medical diagnosis

Question 36

collaborative interventions

Answer 36

-interdependent nursing interventions that require expertise of multiple health care professions

Question 37

direct care

Answer 37

interventions performed though interactions with patients at the bedside

Question 38

indirect care

Answer 38

interventions performed away from the patient on behalf of the patient

Question 39

Cognitive Domain

Answer 39

the thinking domain; client must think through the information presented to them and be able to comprehend the information

Question 40

affective domain

Answer 40

involves the clients feelings, precisely their values, attitudes, and beliefs

Question 41

psychomotor domain

Answer 41

learning based on action; involves physical movement skills, coordination and use of senses

Question 42

crackles

Answer 42

wet, popping sounds created by air moving through liquid or by collapsed alveoli snapping open on inspiration

Question 43

wheezes

Answer 43

continuous sounds caused by air moving through constricted airways; high-pitch common in asthma or low pitch

Question 44

rhonchi

Answer 44

low pitched wheeze that may clear with coughing

Question 45

location of apical pulse

Answer 45

5th IC space, mid-clavicular line