Understanding Medication Reconciliation & Cardiovascular Assessment in Aging Adults, Exams of Nursing

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NR 302 Final Exam Concept Review- Health

Assessment Questions and Answers 2024

What is the definition of a proficient nurse? A nurse who has added time on top of their 2-3 years experience and understand the patient's situation as a whole and applies long term goals What is the definition of a expert nurse? A nurse who has a mastery of an area of learning and performance is based on clinical judgement using intuitive analysis Who determines the recommendations for immunizations? The CDC What should be taken into consideration when assessing recommendations for immunizations?

• Lifestyle
• Occupation
• Travel What is a medication reconciliation? A comparison of current medications versus prior medications lists What should be noted in medication reconciliation?
• Name of meds
• Med dosage

• Schedule of med intake (when / how long/ how many x's per day)
• If they stopped, what was their reasoning What does medication reconciliation do?
• Reduces risks of errors
• Promotes patient safety What does the P in PQRST mean? Provocative or palliative What does the Q in PQRST mean? Quantity or Quality What does the R in PQRST mean? Region or Radiation What does the S in PQRST mean? Severity (0- 10 pain scale What does the T in PQRST mean? Timing of onset What does the U in PQRSTU stand for? Understanding patient's perception of problem

What is a Review of systems? An account that evaluates past / present state of each body part What should one record during a review of systems?

• Subjective data only
• patients statements (subjective)
• Only relevant body parts What does Orientation mean? The awareness of the objective world in relation to the self What does orientation process include?
• time
• place
• person What does Alert mean?
• Patient is fully aroused and oriented
• Fully aware of external / internal stimuli and responds appropriately
• conducts meaningful interpersonal interactions What does lethargy mean?
• Patient is not fully awake
• Patient drifts off to sleep when not stimulated
• Can be aroused to name when called in normal voice but looks drowsy
• responds appropriately to questions or commands but thinking seems slow / fuzzy
• inattentive

• loses train of thought
• spontaneous movements are decreased What is a coma?
• Patient is completely unconscious
• no response to pain or any external or internal stimuli What is a light coma?
• Patient has some reflex activity but no purposeful movement What is a deep coma?
• Patient has no motor response What does delirium mean?
• Clouding of consciousness
• inattentive
• incoherent conversation
• impaired recent memory / confabulatory of recent events
• often agitated and has visual hallucinations
• disoriented w/ confusion worse at night when environmental stimuli are decreased What does the A in ABCT mean? Appearance

What aspects does a nurse look at when assessing a patient's appearance?

• Dress
• Posture
• Body movements
• Grooming / hygiene What is the definition of subjective data? Anything the patient tells you regarding their reason for visit symptoms What is an example of subjective data? Patient stating "My stomach hurts really badly" What is the definition of Objective Data?
• Signs
• Anything the nurse observes with their 5 senses
• Lab work What are some examples of objective data?
• Pulse
• Temperature
• Palpation What does the "A" ADPIE mean? Assessment

What does the "D" ADPIE mean? Diagnosis What does the "P" ADPIE mean? Planning What does the "I" ADPIE mean? Implementation What does the "E" ADPIE mean? Evaluation What is the definition of a novice nurse? A nurse just starting in the industry with less then 2 years experience and uses rules / protocols to guide performance What is the definition of a competent nurse? A nurse with approximately 2 - 3 years experience that can see action in the context of the patients goals / plans What does the B in ABCT stand for? Behavior What aspects does a nurse look at when assessing a patient's behavior?

• Patient's level of consciousness
• Speech

• Facial expressions
• Mood / affect What does the C in ABCT stand for? Cognition What aspects does a nurse look at when assessing a patient's Cognition?
• Orientation
• Attention space
• Recent memory
• Remote memory What does the T in ABCT stand for? Thought process What aspects does a nurse look at when assessing a patient's Thought process?
• Did the client make sense?
• Can you follow the patient?
• is the patient logical?
• did the patient complete their thought?
• is the patient aware of their reality? What is the definition of pulse? Palpable flow felt in the periphery as a result of pressure generated from the stroke volume What is the technique used to assess the pulse?

Palpate radial pulse at flexor aspect of wrist laterally along the radius bone until strongest pulsation is felt (along the thumb side of the wrist) How does one count a regular rhythm pulse? Count 30 seconds Multiply (x) by 2 How does one count a irregular rhythm pulse? Count full 60 seconds (1 minute) What is the normal heart rate? 60 - 100 bpm What is bradycardia? Slow heart rate that can be observed in well-train athletes

• HR < 50 bpm What is tachycardia? fast heart rate
• HR > 100 bpm What is a normal heart rhythm? Regular and even tempo What is sinus dysrhythmia?

• irregular heart rhythm that has a varied rhythm based on respiratory cycle how does a nurse determine a irregular heart rhythm? Nurse would auscultate for heart sounds What does heart force mean? (AKA force of pulse) indicator of strength of heart stroke volume What does a weak/ thready pulse reflect? decreased stroke volume What does a Full / bounding pulse indicate? increased stroke volume What is a Full / bounding heart force (pulse) recorded as?

What is a normal heart force (pulse) recorded as?

What is a weak / thready heart force (pulse) recorded as?

What is a absent pulse reported as? 0 How does an increase in cardiac output impact blood pressure? it causes an increase in BP

How does a decrease in cardiac output impact blood pressure? it causes an decrease in BP What are some temperature changes that occur due to the aging process?

• Less likely to have fevers
• More likely to have hypothermia
• sweat gland activity diminishes What are some pulse changes that occur due to the aging process?
• Rhythm is slightly irregular
• Radial artery may become stiff, rigid, tortuous
• Pulse may be easier to palpate What respiratory changes occur due to the aging process?
• decrease in vital capacity
• inspiratory reserve volume decreases
• increase in respiratory rate What are some blood pressure changes that occur due to the aging process?
• Aorta / major arteries tend to harden with age
• systolic pressure increases
• diastolic pressure increases What are the Major risk factors that lead to hypertension?

• age
• gender
• race
• diurnal rhythm
• weight
• exercise
• emotions
• stress What gender tends to have a higher BP after puberty? Men how does post menopause impact female patient's BP? causes an increase in BP What is the best indicator of pain? Self-report by client is best What type of data is pain? Subjective What are some physiological responses to poorly controlled chronic pain?
• Patients become adaptive to pain
• little indication of pain is given What is chronic pain?

• Pain lasting longer than 6 months what is acute pain?
• Short-term
• self-limiting
• self-protective response
• incidence of pain What does pain signify in the aging adult?
• Pain is commonly reported experience with client's 65 years old +
• Not a normal part of aging
• no evidence that pain is perceived to a lesser degree or pain sensitivity diminishes What are common signs / symptoms of chronic pain?
• Bracing
• Rubbing
• Diminished activity
• sighing
• change in appetite What is the difference between chronic pain vs acute pain? Chronic = 6 months + length Acute = Short lived What are some changes to the nails as an individual ages?

• Longitudinal ridges become more prominent
• growth rate decreases
• toenails thicken What are some changes to the skin as an individual ages?
• begins to undergo slow atrophy and begins to fold / sag
• becomes parchment thin, lax, dry and wrinkled
• skin becomes less elastic What are some changes to the sweat/ sebaceous glands as an individual ages?
• decreased in number / function
• causes xerosis
• cause pruritus What is Xerosis?
• dry skin What are some changes to the hair as an individual ages?
• decreased melanocytes function in hair matrix
• hairs become gray / white
• hairs become thin / fine What is Cherry (senile) angiomas?

• Slightly raised / smooth bright red dots
• Appears on trunk of body What is senile lentigines?
• Common various of hyperpigmentation commonly found in aging adults
• aka "liver spots" What does senile lentigines look like? cluster of melanocytes that appear after extensive sun exposures What are some preventative strategies for skin cancer?
• sunscreen (SPF >/= 15 )
• Avoid peak hours 10am - 4pm
• Avoid tanning / UV tanning beds
• cover up w/ clothing
• avoid being sunburnt What is pallor? Loss of red/ pink undertones due to blood loss and skin takes on color of connective tissue (collagen or white colors) What causes pallor?
• anemia
• shock
• arterial insufficiency
• hypothermia

• cigarette smoking
• edema What is cyanosis? a bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood.
• decreased perfusion Where can you observe cyanosis?
• nose
• lips
• ears
• oral mucous membranes What causes cyanosis?
• hypoxia
• shock
• cardiac arrest
• heart failure
• chronic bronchitis What is jaundice? yellowing of the skin causes by increased bilirubin in the blood What causes jaundice?
• hepatitis
• cirrhosis

• sickle-cell disease
• transfusion reaction What is erythema? intense redness of the skin from excess blood (hyperemia) in the dilated superficial capillaries What are signs of erythema?
• Fever
• local inflammation
• emotional reactions
• increased skin temperature What causes erythema?
• polycythemia
• venous stasis
• carbon monoxide poisoning Where can can you see pallor?
• Junction of Soft / Hard palate of mouth
• Sclera Where can can you see cyanosis?
• lips
• nose
• cheeks

• ears
• oral mucous membranes
• artificial fluorescent light Where can can you see Jaundice?
• Junction of hard / soft palate of the mouth
• sclera
• eyes appear yellow afterwards Where can can you see erythema?
• Skin areas (edema may occur)
• dark skinned patients: need palpation for increased warmth/ taut pulled surfaces What does the A in ABCDEF mean? Asymmetry What does the B in ABCDEF mean? Border irregularity What does the C in ABCDEF mean? Color variation What does the D in ABCDEF mean? Diameter What does the E in ABCDEF mean? Elevation or evolution

What does the F in ABCDEF mean? Funny looking What does a nurse do when assessing the asymmetry of skin dangers?

• whether it is regularly round or oval
• whether two halves of lesion do not look the same What does a nurse do when assessing the border irregularity of skin dangers? look for:
• notching
• scalloping
• ragged edges
• poorly defined margins What does a nurse do when assessing the Color variation of Skin dangers? Nurse assesses whether there has been color variations within the skin What does a nurse do when assessing the Diameter of skin dangers? whether or not the area is greater (>) 6 mm What does a nurse do when assessing the Elevation or evolution of skin dangers? Whether or not the area is raised or not What does a nurse do when assessing the Funny looking of skin dangers? does the area look different than any other lesion around it? What is a macule?

flat circumscribed <1.0 cm What is an example of a macule?

• Freckles
• Flat nevi
• Hypopigmentation
• measles What is a papule?
• Raised area of the skin
• Caused by superficial thickening of the epidermis
• < 1 cm What is an example of a papule?
• elevated nevus (Mole)
• lichen planus
• wart What is a vescile?
• elevated cavity containing free fluid
• < 1 cm What is an example of a vesicle?
• Herpes simplex
• Chicken pox (early varicella)

• Herpes Zoster (shingles)
• Contact dermatitis What assessment technique is used to assess skin texture?
• Palpation is used What is a stage 1 pressure ulcer called? Non-blanchable erythema What does a stage 1 pressure ulcer look like?
• skin is intact
• skin is red
• skin is unbroken
• pigmented skin does not blanch What is a stage 2 pressure ulcer called? Partial-thickness skin loss What does a stage 2 pressure ulcer look like?
• loss of epidermis
• dermis is exposed
• superficial ulcer that looks shallow like an abrasion
• red wound bed
• no visible fat or deep tissue seen

What is a stage 3 pressure ulcer called? Full-thickness skin loss What does a stage 3 pressure ulcer look like?

• injury extends into subcutaneous tissue
• resembles a crater
• can see subcutaneous fat
• can see granulation tissue
• rolled edge What is a stage 4 pressure ulcer called? Full-thickness skin / tissue loss What is a stage 4 pressure ulcer look like?
• PI involves all layers of the skin
• extends into supporting tissue
• exposed muscle
• exposed tendons / bones
• may show slough or eschar
• rolled edges
• tunneling What is Herpes Zoster? Small, group of vesicles emerging around the route of the cutaneous sensory nerve
• pustules
• then crusts over

Where does Herpes Zoster emerge at? around cutaneous sensory nerve What bacteria causes herpes zoster? Varicella zoster virus (VZV) What is varicella zoster virus (VZV)? A dormant virus of chickenpox Where can you see herpes zoster mainly? around the trunk of the body What causes poor skin turgor?

• Severe dehydration
• Delayed capillary refill
• Tachypnea
• Malnutrition
• Extreme weight loss What are some changes that occur in the face / head as a result of the aging process?
• Facial bones appear more prominent
• orbits appear more prominent
• Facial skin begins to sag
• lower face appears smaller if teeth have been lost Why does skin begin to sag?

• due to decreased elasticity
• due to decreased subcutaneous fat?
• due to decrease moisture in skin What is a cluster headache? Rare HA that is intermitted, excruciating, unilateral w/ automatics signs that occur on one side of the mouth What are the characteristics of a cluster headache?
• Continuous HA
• Burning
• Piercing
• Excruciating What are some triggers of cluster headaches?
• Alcohol
• Stress
• Smoking
• Daytime napping
• Wind / heat exposure What is some symptoms of Cluster headaches?

• Nasal congestion
• runny nose
• watery / reddened eye
• eyelid drooping
• miosis
• feeling agitated What are some treatments / relief for cluster headaches?
• Having the patient move around
• Having the patient pace the floor What is a migraine? Headache that is genetic in origins and typically cause throbbing / pulsating pain in the supraorbital, retroorbital, and trigeminal nerve How long do chronic headaches last?

15 days / months How longs does acute headaches last? < 15 days / months Characteristics of migraine headaches?

• Throbbing pain
• Pulsating pain What are triggers of migraine headaches?

• Hormonal fluctuations
• foods
• hunger
• let down after stress
• sensory stimuli
• change in weather
• sleep deprivation What are some foods that trigger migraines?
• alcohol
• caffeine
• chocolates What are some symptoms of migraine headaches?
• Aura
• Prodrome
• Nausea
• Vomiting
• Person looks sick
• visual disturbances What is some relief / treatment of migraine HA?
• lie down
• dark rooms
• quiet rooms
• use eyeshade
• sleep