Study with the several resources on Docsity
Earn points by helping other students or get them with a premium plan
Prepare for your exams
Study with the several resources on Docsity
Earn points to download
Earn points by helping other students or get them with a premium plan
Community
Ask the community for help and clear up your study doubts
Discover the best universities in your country according to Docsity users
Free resources
Download our free guides on studying techniques, anxiety management strategies, and thesis advice from Docsity tutors
NR302 EXAM 3 QUESTIONS AND CORRECT VERIFIED ANSWERS LATEST UPDATED 2024/2025 A COMPLETE BEST SOLUTION GRADED A+ FOR SUCCESS
Typology: Exams
1 / 21
complete/ total assessment - CORRECT ANSWERS establishes the database for client and is often collected in a primary care setting such as clinic or time of admission Includes detailed health history, a full physical assessment and an initial diagnosis Focused(Problem-centered) assessment - CORRECT ANSWERS when a client is experiencing a short-term, non-life threatening problem such as rash used to collect data related to a specific problem or short-term need. The focus is centered on one problem (rash or request for a vaccination), one cluster of cues (fever, dry cough, fatigue, and loss of taste and smell), or one body system (neurologic or cardiovascular). follow up assessment - CORRECT ANSWERS routinely completed to monitor the health status of persons chronic diseases client with fever on the second day after surgery individual with stable heart failure emergency assessment - CORRECT ANSWERS completed when a clients safety of life is in imminent danger such as during a cardiac arrest what determines the frequency of assessment needed for each individual - CORRECT ANSWERS The person's health and wellness needs holistic health - CORRECT ANSWERS Holistic health believes health is a complex state influenced by the entire person (mind, body, and spirit) and their environment Views the mind, body, and spirit as vital to overall wellness. Disease results from factors within and outside of the body.
Each person is an active part of their own health and wellness. rapid (screening) assessment - CORRECT ANSWERS also known as ABCs (airway, breathing, circulation) abdominal assessment techniques - CORRECT ANSWERS IAPP inspection(see,smell) , auscultation(hear) percussion(hear), palpation(feel) database for a person who is ill - CORRECT ANSWERS the complete assessment adds a description of their health problems, their perception of illness, and their response to the alterations in health. In addition to a physical assessment, the nurse assesses the individual's perception of illness, functional ability or patterns of living, activities of daily living, health maintenance behaviors, response to health problems, coping patterns, interaction patterns, spiritual needs, and health goals Diaphragm detects - CORRECT ANSWERS higher pitched sounds abdominal assessment techniques - CORRECT ANSWERS IAPP inspection (see/smell) auscultation(hear) percussion(hear) palpation(feel) Inspection - CORRECT ANSWERS purpose is to discover any visual abnormalities such as bruising, bumps masses, or visible pulsations. inspection is best completed in an area with good lighting to better visualize color and textures while avoiding shadows.
Palpation - CORRECT ANSWERS Provides information related to texture, temperature, moisture, organize and location, swelling vibration, pulsation, firmness, lumps, or masses in the presence of pain or tenderness Light Palpation-used to feel for surface abnormalities, uses light touch with finger pads the depresses skin half inch to three-quarter inch Deep Palpation-used to feel internal organs and masses for size, shape, tenderness symmetry, and mobility, depresses the skin 1 1/2 to 2 inches with firm deep pressure one hand on top of other and finger pads percussion - CORRECT ANSWERS Tapping fingers or hands quickly and sharply against persons, body to assess for pain or tenderness locate Oregon borders I identify or can shape and position and determine if an organ is solid, or filled with fluid or gas Direct percussion-used to assess for tenderness, one or two fingers tap directly on the body part Indirect percussion-generate sounds that provide cues to the substance of underlying tissue Structures with more air produce a louder, deeper sound, and denser or solid structures, give off softer higher, shorter sounds auscultation - CORRECT ANSWERS Uses stethoscope to listen to sound generated by various organs within the body health history - CORRECT ANSWERS comprehensive record of a clients past and present health status Biographic data : Reason for seeking care : Present health or history of present illness Past history :
Medication reconciliation Family history : Review of systems : Functional assessment sign - CORRECT ANSWERS objective detected by physical examination or through diagnostic testing symptom - CORRECT ANSWERS Subjective feeling a client has Biographic data - CORRECT ANSWERS Information about a persons identity name, address, phone number, age, birthdate, gender, marital status, race, ethic origin, occupation, primary language Reason for seeking care - CORRECT ANSWERS brief statement from client describing reason for a visit Documented in quotes, indicating that these are the clients words. It is not diagnostic statement by the examiner. Present health or history of present illness - CORRECT ANSWERS statement of general health Purpose is to collect as much data about the reason for seeking care as possible Ask PQRSTU PQRSTU - CORRECT ANSWERS Provocative or palliative(what makes the symptom worse or better?) Quality or quantity(what does the sentence feel like? If one or more feelings which one is worse?)
Region or radiation(where is the symptom? Is it located anywhere else?) Severity scale(scale of 0 to 10 read the symptoms) Timing(when did the symptoms begin?) Understanding the patient's perception of the problem.( How has the symptom affected you?) Past history includes - CORRECT ANSWERS prior major illnesses, hospitalization, or surgeries Includes childhood, illnesses, accidents, or injuries Medication reconciliation - CORRECT ANSWERS accurate list of current medication, and dosages Process of comparing the medication's prescribed with the medication's the client is taking. Examiner will address duplications omissions interactions, and they need to continue the medication Family history - CORRECT ANSWERS Mapping of familiar, illnesses and diseases Documents to biological relationships and medical history of a client. It's used to recognize health patterns and shared risk. Can be collected using a detailed questionnaire or depict that individual chart called a pedigree or genogram Review of systems - CORRECT ANSWERS client description of the health of each of their body system Inventory of each body system, through a set of questions that help identify other sentence related to the present illness and health promotion practices
Includes the date of the client's last physical exam and other health promotion practices Functional assessment - CORRECT ANSWERS Measures the clients ability to complete task and activities associated with the living. Functional status is important for clients who have chronic illnesses, disabilities, or age related challenges. Do use of tobacco, alcohol and recreational drugs is part of personal habits section of the functional assessment Abuse seek medical care if client exhibits - CORRECT ANSWERS Signs of dehydration Shortness of breath Chest pain Confusion or dizziness Worsening of chronic conditions general survey - CORRECT ANSWERS Collect objective data about the individuals, general health lifestyle choices that may impact health and knowledge deficits to address with health education First impression in the assessment process What is included in the general survey? - CORRECT ANSWERS Body structure Mobility Behavior Physical appearance physical appearance - CORRECT ANSWERS Observes for
Age (do they look their age) Level of consciousness (is client alert/oriented) Skin color (is skin tone, even intact or is there any lesions?) Sexual development (developed appropriately for age) Facial features (symmetrical?) overall appearance (any signs of distress) behavior - CORRECT ANSWERS Observing the client's dress, grooming, and personal hygiene Mood ,manner,facial expressions and speech body structure - CORRECT ANSWERS Stature Are the clients height normal weight Symmetry Is the body symmetric proportional? Posture Position Describing the clients position (sitting,standing,leaning) Does the client uses assistive devices? (Cane,walker) mobility - CORRECT ANSWERS Observing the clients range of motion and gait as they move Range of motion- full mobility of each joint and coordinated movement
Gait-the patient movements around the room are the movements coordinated normal base is as wide as shoulder smooth even foot placement symmetry of arm and legs nutrition - CORRECT ANSWERS Nutritional status is the degree of balance between nutrients intake and nutrient requirements Nutritional assessment techniques - CORRECT ANSWERS Height Weight Body mass index Waist circumference Abnormal findings - CORRECT ANSWERS Physical appearance(appears older, confused and drowsy, cyanosis, jaundice or any lesions) Body structure (excessively short or tall, obesity or malnourished, rigidity or tripod position) Mobility (shuffling, paralysis, tremors) Behavior (depressed, angry, dysphasia, body odor, not a properly dressed for the season) Vital signs - CORRECT ANSWERS Measurement of temperature, pulse, respiration , blood pressure and oxygen saturation Vital signs are taken Upon admission before and after surgery or certain medication As ordered Temperature - CORRECT ANSWERS Measurement of the difference between heat production and heat loss
Baseline Oral-98.6°F Rectal - 98.6°F Axiliary (armpit)-97.6°F Tympanic (ear)-99.6°F Temporal Artery (forehead)-97.6°F 97°to 99°F (normal body temp) Over 105°F(hyperthermia) Below 95°F (hypothermia) pulse - CORRECT ANSWERS Rhythmic beating or vibrating movement in the body. Each pulse beat corresponds to a contraction of the heart. Radial (wrist) and carotid arteries(neck) are common palpated pulse sites Count pulse for 30 secs then x by 2 Normal adult pulse rate (60 to 100 beats per minute) Tachycardia (faster than 100 beats per minute) Bradycardia (slower than 60 beats per minute) The condition of the heart age, gender, emotional state, size temperature, and amount of physical activity can influence pulse rate. Doppler ultrasound can be used to hear weak pulse tachycardia - CORRECT ANSWERS Pulse is faster than 100 beats per min
Can be caused by shock hemorrhage, hypovolemia, exercise, fever, medication, substance, use acute pain in some drugs, such as epinephrine Bradycardia - CORRECT ANSWERS Pulse rate slower than 60 bpm Can be caused by some drugs, such as beta blockers, that lower heart rate , resting in supine position, heart block. respiration - CORRECT ANSWERS Inspiration and expiration of air that is controlled by the medulla oblongata in the brain Normal respiratory for an adult (12 to 20 respirations per minute) Tachypnea(rapid respiration, above 20 respirations per minute ) Bradypnea ( slow respiration, below 12 respiration per minute ) Tachypnea - CORRECT ANSWERS rapid respiration rate above 20 respirations per minute Exercising fever can increase respiratory rate Bradypnea - CORRECT ANSWERS a slow respiration rate below 12 respiration per minute Hyperventilation - CORRECT ANSWERS When the rate of ventilation exceeds normal metabolic requirements for exchange of respiratory gases, for example, during emotional trauma, volume and depth of respiration increases hypoventilation - CORRECT ANSWERS Occurs when the rate of ventilation entering, the lungs is insufficient for metabolic needs. Respiratory rate is below normal, and depth of ventilation is depressed. sites for finding pulse - CORRECT ANSWERS Carotid (best) Radial Femoral Brachial artery
Apical pulse in infants/tachycardia/ if radiation pulse is abnormal Pupil - CORRECT ANSWERS Opens and closes to adjust the total amount of light entering the eye. blood pressure - CORRECT ANSWERS The force of blood, as it is circulated by the heart Composed of high number (systole) And low number (diastole). S/D Normal BP 120/ High BP 129/79 (chronic high bp is hypertension) Low BP 100/50 (experiences, dizziness, lightheadedness) oxygen Saturation - CORRECT ANSWERS The percentage of total hemoglobin that is carrying oxygen Normal values are above 95% Systole - CORRECT ANSWERS Amount of pressure in the arteries, when the ventricles of the heart are contracting and pushing blood forward First sound heard S/D Diastole - CORRECT ANSWERS The pressure within the artery when the ventricles are relaxed and filling with blood S/D Development Competence - CORRECT ANSWERS If kids are reaching age and developmental milestone that are expected
Head and chest circumference development of older adults - CORRECT ANSWERS Shrink- cyphosis of spine bones shrink Less muscle Types of Dwarfism - CORRECT ANSWERS Hypopituitary Achondroplastic hypopituitary dwarfism - CORRECT ANSWERS growth hormone deficiency short stature achondroplastic dwarfism - CORRECT ANSWERS a condition caused by defective cartilage formation that results in improper bone development Short limbs acromegaly - CORRECT ANSWERS Growth of jaw and limbs and organs as an adult 90% of patients have tumor in pituitary Giantism - CORRECT ANSWERS Excess growth hormones endogenous obesity - CORRECT ANSWERS obesity caused by a decrease in metabolism resulting from a disturbance of hypothalamic or endocrine functions Cushing's syndrome - CORRECT ANSWERS a condition caused by long term exposure to high levels of cortisol Uneven fat distribution in the body Caused by medication or tumor in pituitary
Fat pad on back Moon face Dyspnea - CORRECT ANSWERS difficulty breathing function of integumentary system(skin) - CORRECT ANSWERS temperature regulation protects against trauma and infection lifestyle choices that affect the skin - CORRECT ANSWERS diet occupation hobbies smoking uv exposure Skin Assessment - CORRECT ANSWERS should include inspection and palpation. color and pigmentation Integrity (skin breakdown) Turgor (elasticity) moisture Braden Scale for Predicting Pressure Sore Risk - CORRECT ANSWERS predicts risk for pressure injuries measures moisture, nutrition, mobility and sensory perception in addition to activity, friction and shear skin cancer - CORRECT ANSWERS most common type of cancer 1 in 5 people in the US develop
ABCDE - CORRECT ANSWERS mnemonic for assessing moles. A- asymmetry border B- border irregularity C- color that is not uniform D- diameter greater than 6mm E- evolving size,shape or color Hair abnormalities - CORRECT ANSWERS alopecia areata dry scalp seborrheic dermatitis (dandruff) Lice Ringworm Hirsutism Nail abnormalities - CORRECT ANSWERS clubbing yellow nails (smoking) cyanotic nail beds jagged nails with torn cuticles fungal nail infection (onychomycosis) developmental influences of skin, hair, nails - CORRECT ANSWERS Infants lack subcutaneous fat and body hair and cannot prevent fluid loss or protect against temp change Pregnancy Hormones causes pigment changes. Birthmarks, moles and freckles may darken Stretching of abdominal skin resulting in striae
Older Adults Thinning of skin and loss of subcutaneous fat results in decreased temperature regulation and protection from injury. Increased tears and loose skin Skin conditions - CORRECT ANSWERS Skin cancer Age spots Eczema Acne Keloids Types of skin cancer - CORRECT ANSWERS basal cell carcinoma, squamous cell carcinoma, malignant melanoma Common skin lesions - CORRECT ANSWERS Plaque (psoriasis) Bullae (clear fluid filled blisters >10mm. ex:burns) Pustules (pus-filled vesicles ex:acne) Vesicles (clear fluid filled <10mm) ex: herpes) Papules (wart) Wheal (hives) Macule (freckles) Nodule (lipoma) Sunscreen - CORRECT ANSWERS use broad spectrum sunscreen with at least 30 SPF Reapply every 2 hrs To determine if a darker skin patient has cyanosis check - CORRECT ANSWERS Mucous membrane Nailbeds
Melanoma treatment - CORRECT ANSWERS Stage 1- Surgery Stage 2 - Surgery/Biopsy Stage 3- Surgery, Immunotherapy or targeted therapy drugs Stage 4- Surgery, radiation, immunotherapy, targeted therapy, chemotherapy Stage 5 - stage 4 plus clinical trials bell detects - CORRECT ANSWERS low pitched sounds (murmur) Risk factors for head and neck - CORRECT ANSWERS not using safety equipment such as helmets and seat belts alcohol or drug consumption risk factors for the nose, mouth and throat - CORRECT ANSWERS cigarette, vape, cigar, or chewing tobacco use lack of routine dental care not practicing proper hand hygiene and infection prevention practices poor nutritional intake Lymph nodes - CORRECT ANSWERS A network of vessels that collect and filtrate fluid produced by immune response Largest network found in neck area Should be bean shaped, usual less than 1cm, soft, non-tender and slight movable Throat assessment - CORRECT ANSWERS uvula is intact Back of throat is pink and moist inside of cheek is free from lesions/injury roof of mouth is intact
Fontanelle - CORRECT ANSWERS space between the bones of the skull in a newborn where the sutures are not fully formed Abnormalities of head and neck - CORRECT ANSWERS headaches head deformities thyroid gland disorders fetal alcohol syndrome Down syndrome Parotid gland syndrome Abnormalities of nose, mouth and throat - CORRECT ANSWERS nasal deformities lip lesions or cracking tooth decay, gingivitis or tooth loss infection of pharynx Concussion - CORRECT ANSWERS caused by acceleration- deceleration force after a mechanical force hits the head enlargement of the thyroid gland can be caused by - CORRECT ANSWERS hyperthyroidism ( too much hormone) Hypothyroidism (too little hormone) signs and symptoms of hypothyroidism - CORRECT ANSWERS weakness, goiter, dry skin, fatigue and constipation Low T High TSH treatment for hypothyroidism - CORRECT ANSWERS life long synthetic T4 hormone levothyroxine restores the depleted hormone levels and reverses the signs and symptoms
Eye assessment - CORRECT ANSWERS Snellen eye chart PERRLA Diagnostic positions test Pupil Gauge (measures size of pupil 3,4 or 5mm is normal Risk factor for eyes and vision loss - CORRECT ANSWERS family history smoking/ alcohol use Uv damage Poor nutrition Retinal changes Risk factors of hearing impairment - CORRECT ANSWERS genetic predisposition for hearing loss Loud music Chronic ear infections Cerumen buildup Parts of the eye - CORRECT ANSWERS pupil is at the center of the eye Iris is colored part of the eye white space is sclera PERRLA - CORRECT ANSWERS Pupil Equal Round Reactive to Light and Accommodation
pupils equal, round, reactive or constrict to light and accommodate changes in pupil dilation when assessing objects both near and distant. Vision - CORRECT ANSWERS Higher the second number the worse the vision Ex: 20/ You can see items clearly at 20 feet which most people can see clearly at 30 feet Ear Assessment - CORRECT ANSWERS whispered voice test tuning fork test ( measures hearing by air conduction (AC) or bone conduction (BC). Air conduction should be greater than bone conduction (AC>BC) The Weber test (detects sensorineural loss) Rinne test (detects conductive hearing loss) Pinna position - CORRECT ANSWERS when looking into ear canal with an otoscope remember to pull the pinna up and back for adults and down for infants and children under 3 Common age related change in the ears with aging - CORRECT ANSWERS coarse and stiff cilia(lining in the ear) cause cerumen to accumulate and oxidize which may greatly reduce hearing loss Abnormal findings of the eye - CORRECT ANSWERS extraocular muscle dysfunction external structure abnormalities eyelid lesions Pupil abnormalities Visual field loss Vascular disorders Internal structure abnormalities Abnormal findings of the ear - CORRECT ANSWERS external structure abnormalities
Hearing loss Ear lesions Internal structure abnormalities Eustachian tube - CORRECT ANSWERS tube that runs between the middle ear and the back of the nose can be obstructed by allergies causing feeling of pressure or fullness Hay fever - CORRECT ANSWERS An allergic response usually to outdoor airborne allergens such as pollen or sometimes indoor allergens such as dust mites or pet dander; also called allergic rhinitis symptoms of hay fever - CORRECT ANSWERS Fatigue Headache Itchy red watery eyes Loss of sleep Runny or blocked nose Painful temple and forehead Ear congestion Sneezing and coughing Itchy throat mouth and ears Seeing under eyes dysphasia - CORRECT ANSWERS difficulty swallowing Which is a common cause of of dysphagia in older adults - CORRECT ANSWERS Stroke Pallor - CORRECT ANSWERS Pale Cataract - CORRECT ANSWERS clouding of the lens of the eye
presbycusis - CORRECT ANSWERS age related hearing loss Tinitus - CORRECT ANSWERS ringing in the ears Otitis media - CORRECT ANSWERS middle ear infection Cheyne-Stokes - CORRECT ANSWERS Abnormal breathing characterized by periods of dyspnea followed by periods of apnea is called... eardrum - CORRECT ANSWERS tympanic membrane ptosis - CORRECT ANSWERS drooping A 60-year-old man is at the clinic for an eye examination. The nurse suspects that he has ptosis of one eye. How should the nurse check for this? - CORRECT ANSWERS Observe the distance between the palpebral tissures. Hearing loss due to inefficient conduction of sound waves through the outer ear canal to the eardrum and ossicles of the middle ear is called: - CORRECT ANSWERS Conductive hearing loss Dysarthria - CORRECT ANSWERS difficulty speaking