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Nursing A&S Final Exam Latest Study Guide
Priority assessment ABCS - airway, breathing, circulation -the nurse should place priority on assessing the clients respirations -noting the rate and pattern -evaluate oxygen saturation The interview -use open ended question to obtain more information in interview -use therapeutic communication -active listening (listening to the patient without judgement) -empathy and compassion -consider hearing and visual impairments Previous Play Next Rewind 10 seconds Move forward 10 seconds Unmute 0: / 0: Full screen Brainpower Read More Communication with those who are visually impaired
ensure large fonts. Assess how visually impaired they are: (What can you see?) Communication with those who are hearing impaired Reduce background noise if hearing impaired prior to conduction of health history -provide things in writing, ask them to repeat back to confirm they understand. Techniques and sequencing or physical for abdomen inspect auscultate percuss palpate Techniques and sequencing or physical for other body systems inspect palpate percuss auscultate Documentation must ensure confidentiality in electronic and charting records Interview preparation -review patient record -allow sufficient time -ensure good lighting
Always start the interview by asking open ended questions, then you can ask specific questions part of the mnemonic pack years
of packs per day X # of years smoked
2 packs a day smoked for 20 years = 40 pack years Vital signs normal vs abnormal temperature: -97.5°F to 99.5°F
- <97.7°F to >100.4°F radial pulse: -60-100 bpm, rhythm is regular, amplitude is = -<60 and >100, rhythm is irregular, amplitude is absent/weak apical abnormal findings = if rhythm is irregular w/ pauses, may be indicative of an irregular HR respiratory: -12-18 breaths per minute, pattern is even, rhythm is regular -<12 and >18 breaths per minute, depth is deep or shallow, rhythm is irregular & using accessory muscles to breath
Inspection requires the use of 3 senses hearing smelling seeing -also ensure good lighting Inspection consider the following: -location -size -odor -symmetry -color -pattern -shape Parts of the hand used to palpate finger pads dorsal surface of the hand ulnar surface resonance heard of normal lung fields
Signs of dehydration -poor skin tugor -furrowed tongue -dry mucous membranes -postural hypotension or orthostatic hypotension Overhydration/fluid overload? Edema or ascites, renal failure, liver failure, signs; decreased blood levels of sodium, potassium, albumin, Bun and Creatinine, increase in blood pressure -increased heart rate -increased bp -increased respirations -diluted labs may lead to seizures, dizziness, and strokes CBC lab values -wbc -rbc -hgb
Normal values for WBC's 4500-11, Normal value for RBC male: 4.5-6.0 mill/mm3 female: 4.0-5.5 mill/mm Normal value for hgb men: 13- females: 12- Normal lab value for sodium 135-145 mEq/L Normal lab value for potassium 3.5-5.2 mEq/L (indicates cardiac function) Normal lab value for chloride 95-107 mEq/L Normal lab value for magnesium 1.5-2. Normal lab value for BUN 10-20 mg/dL
Cranial nerve II Optic - vision Cranial nerve III Oculomotor: opening eyelid, moving eye superiorly, medially and diagonally; constricting pupils EOM testing, PERRLA, Cranial nerve IV Trochlear (motor); moving eye down and laterally Cranial nerve V Trigeminal; motor: -chewing and jaw opening and clenching sensory: -corneal reflex and facial sensation Cranial nerve VI abducens; motor. moving eyes side to side Cranial nerve VII facial
motor; closing eyes, mouth, moving lips, eyebrows, smiling sensory: tasting on anterior tongue Cranial nerve VIII Vestibulocochlear (hearing and balance) (perform whisper tests/romberg to test for this) Cranial nerve IX Glossopharyngeal; motor: swallowing, gag sensation, secretes saliva sensory: tasting on posterior tongue Cranial nerve X Vagus motor- palate, pharynx, and larynx, sensory- sensations in pharynx and larynx sensorimotor: cardiovascular respiratory, and digestive systems Cranial nerve XI accessory (spinal) motor: shoulder shrug, contracting muscles of neck and shoulders
Negative babinski (in newborns) infant will not extend the big toe and toes will not fan out; may indicate neurological disorder Neural tube defects malformations of the brain, spinal cord, or both during embryonic development that often result in lifelong disability or death (low folic acid) Folic acid prevents neural tube defects Spina bifida = opening at the end of spine, a form of NTD Glascow Coma scale eye opening, verbal response, motor response Decrease in 2 points is a significant neurological change assess whether if patient has an impaired level of consciousness Glascow coma scale scoring Eye response (4 points) Verbal response (5) Motor (6 points) High score = 15 Low = 3
GCS 13 - 15 = mild head injury GCS 9-12= moderate head inury GCS 3-8 = severe head injury Ensure adequate ventilation Peripheral neuropathy disorder of the peripheral nerves that carry information to and from the brain and spinal cord if a sensory nerve is damaged... What may peripheral neuropathy present with? Numbness Tingling Burning Dull Pain Loss of feeling in extremeties Possible causes of peripheral neuropathy Diabetes Vitamin B12 deficiency
abnormally slow breathing, <12 breaths per min Normal lung sounds bronchial, bronchovesicular, vesicular Abnormal lung sounds adventitious sounds crackles, rhonchi, wheezes, stridor, pleural friction rub In a collapsed lung (pneumothorax), there is no movement, you will only hear air Crackling may indicate fluid going into the lungs as well as air if infected = pneumonia Wheezing caused by narrowed passageways in the trachea-bronchial tree by secretions, inflammation, obstruction, or a foreign body Vital signs that change with left sided heart failure -respiratory congestion ex: hacking cough, frothy sputum, wheezing, fatigue -weakness -SOB
-blood is returning (lungs) Vital signs that change with right sided heart failure -dependent edema -liver and abdominal enlargement -nocturnal urination(too much fluid in the kidneys that can't get rid) -jugular venous distention (body abnormalities) Arterial ulcers pale, cool extremities, with hair loss, atrophy of muscles, thick toenails, intermittent cramping (no blood to legs) Venous ulcers edema -brawny coloring of lower extremities -some leg ulcers -leg veins dont allow blood flow back up to your heart How are arterial and venous insufficiency similar? .
S3 - occurs early in diastole, ventricular gallop (use the bell to listen to in a left lying position) S4 - occurs at the end of diastole - atrial gallop Proper position to listen to heart sounds -supine -fowlers -highfowlers -sitting up or left side lying *NEVER right side lying PMI point of maximal impulse (apical pulse) is the location at which the cardiac impulse can be best palpated on the chest wall. aortic pulse location right sternal border 2nd intercostal space pulmonic pulse location left sternal border, 2nd intercostal space erbs point left sternal border, 3rd intercostal space
tricuspid point left sternal border, 4th intercostal space mitral point/apical left 5th intercostal, medial to midclavicular line atrial fibrillation -irregular pulse -there are changes in apical versus radial pulse What conditions lead to an irregular pulse rate? atrial fibrillation Kyphosis a forward stooping of "hunchbacked" posture w/ loss of height -seen in osteoporosis Lordosis an exaggerated lumbar curvature or "sway back" common in patients who are obese or pregnant
