Physiological Responses and Clinical Manifestations, Exams of Nursing

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NR 304 Final Exam Questions and

Correct Answers

What happens during the evaluation step of the nursing process? - Correct answer Progress towards outcomes, use ongoing assessment to revise diagnoses/outcomes/plans, disseminate results to patient and family What happens during the diagnosis stage of the nursing process? - Correct answer Compare clinical findings with normal and abnormal variation and developmental events, interpret data, validate and document diagnoses. What is a problem center database? Give an example. - Correct answer For limited or short term problems. Collect mini/targeted databases. Focuses on only one problem or body system and is used in all clinical settings. Ex: two days post-op patient suddenly becomes SOB with congestive cough and fatigue; focus on respiratory and cardiovascular systems What are the components of a general survey? - Correct answer Begins during first patient encounter.. Includes their physical appearance, body structure, mobility, behavior, body measurements What is the grading of pulse force? - Correct answer 3+ Full, bounding 2+ Normal 1+ Weak, thready 0 Absent What are causes of hypotension? - Correct answer Acute myocardial infarction, shock, hemorrhage, vasodilation, Addison's disease What is the blood pressure measurement for hypotension? - Correct answer Less than 95/60 mmHg

Acute myocardial infarction and shark causes a _____ cardiac output which leads to hypertension? - Correct answer Decreased Hemorrhage causes a _____ total blood volume that leads to hypotension - Correct answer decreased Vasodilation causes a ____peripheral vascular resistance that leads to hypotension - Correct answer decreased Addison's disease (hypofunction of adrenal gland) is caused by a ___ circulating aldosterone which causes hypotension - Correct answer decreased How do you count respirations? - Correct answer Count while assessing radial pulse to make patient unaware that you were counting respirations. Count for 30 seconds of normal or 1 minute if abnormal What are the effects of smoking on blood pressure? - Correct answer Vasoconstriction of the arteries which makes your blood pressure increase. Long-term cause of hypertension What is the ABCDEF skin lesions mean? - Correct answer Asymmetry, border irregularity, color variation, diameter greater than 6mm, elevation/evolution, funny looking What are the physiological changes associated with acute pain responses?

• Correct answer Tachycardia, elevated blood pressure, increased cardiac output, hypoxia, hypoventilation, atelectasis, decreased cough, nausea, vomiting, ileus, oliguria, urinary retention, spasm, joint stiffness, increased adrenergic activity, fear, anxiety, fatigue, impaired immunity, wound healing How do you assess for clubbing? - Correct answer Put nail beds back to back and view profile sign index. Normal is 160°. Early clubbing is 180° and lake clubbing is anything less than 160° What patients does clubbing occur? - Correct answer Smoking, lung cancer, pulmonary disease, congenital cyanotic heart disease How do you detect pallor in a light skinned patient? - Correct answer Generalized pallor

How do you detect pallor in a dark skinned patient? - Correct answer Ashen gray, dull, loss of glow, cool to palpation How do you detect jaundice in a light-skinned patient? - Correct answer Yellow sclera, hard palate, skin, mucous membranes How do you observe jaundice in a dark skinned patient? - Correct answer Observe the palms, hard and soft palates How do you observe cyanosis in a light skinned patient? - Correct answer Dusky blue appearance How do you observe cyanosis in a dark skinned patient? - Correct answer Dullness, check conjunctiva, oral cavity, nails How do you observe erythema in a light skin patient? - Correct answer Red or bright pink color How do you observe erythema in a dark skinned patient? - Correct answer Purpleish tinge, difficult to observe, palpate for warmth What is the name and characteristics of a stage one pressure injury? - Correct answer Stage 1 non-blanchable erythema Intact skin with a localized area of non-blanchable erythema What is the name and characteristics of a stage 2 pressure injury? - Correct answer Stage 2 partial thickness skin loss Partial skin loss with an exposed dermis. Pink/red and moist visible wound base. Looks like a ruptured blister. Usually associated with moisture. Slough and eschar not noted. What is the name and characteristics of a stage 3 pressure injury? - Correct answer Stage 3: Full-Thickness Skin Loss For thickness loss of skin. Adipose is visible in ulcer and granulation tissue with epibole. Slough and eschar may be noted. Tunneling and undermining may occur. What's the name and characteristic of a stage 4 pressure injury? - Correct answer Stage 4: Full thickness skin/tissue loss

Full thickness skin and tissue loss with muscle/bone/tendon/ligament exposed. Slough, Eschar, epibole, undermining, tunneling may be present. How do you assess the range of motion of the neck? - Correct answer Touch chin to chest, turn head right and left, touch ear with shoulder without elevating the shoulders, extend head backwards What are the manifestations of hypothyroidism? - Correct answer Non- pitting Edema, fatigue, cold intolerance, puffy Edematous face, Peri orbital Edema, puffy hands/feet, course facial/hair features, cool/dry skin, slow reflexes, occasionally thick speech. What are the manifestations of breast cancer? - Correct answer Firm/hard irregular axillary node, skin dimpling, nipple retraction, elevation, discharge What are the complications of a mastectomy? - Correct answer Lymphedema due to the decrease number of lymph nodes What are the inspection techniques for the thorax and lungs? - Correct answer Note shape and configuration of chest wall, anteroposterior (AP) diameter should be less than transverse diameter (if more=barrel chest), note breathing position, skin color and condition ( cyanosis=hypoxia) Describe wheezing? - Correct answer Connected, musical sounds, sounds like a kazoo Describe crackles? - Correct answer Discrete, crackling sound. Popping/crackling What clinical patients would you expect to have Adventitious lung sounds of crackling? - Correct answer Pulmonary edema, pneumonia, pulmonary fibrosis, terminally ill with depressed cough reflex, heart failure, interstitial fibrosis, chronic bronchitis, asthma What are the indications of tachypnea and when do they occur? - Correct answer Rapid, shallow breathing, increase rate. 24+ BPM. Normal response to fever, fear, exercise. Occurs with respiratory insufficiency, pneumonia, alkalosis, pleurisy, pons lesions.

What are the manifestations of a pulmonary embolism? - Correct answer 95% of the time due to a DVT, hypoxia, decreased cardiac output, Dyspnea, chest pain that's worse on inspiration, apprehension, restlessness, anxiety, cyanosis, mental status change, cough, hemoptysis, diaphoresis, hypertension, wheezing, crackles, tachycardia What are the manifestations of asthma? - Correct answer Complex bronchospasm, inflammation, bronchial Edema, mucus secretions, wheezing, Dyspnea, chest tightness, decreased breath sounds, cyanosis, accessory muscle use, labored and prolonged breathing What are the manifestations of right sided heart failure? - Correct answer Dilated peoples, pale/gray/cyanotic skin, decreased blood pressure, nausea/vomiting, ascites, dependent pitting edema, anxiety, confusion, JVD, infarct, fatigue, tachycardia, murmurs, decreased urine output, weak pulse, cool/moist skin What happens during right sided heart failure? What type of manifestations does it cause? - Correct answer Blood backs up into the body and causes systemic signs What happens during left-sided heart failure? What type of manifestations does it cause? - Correct answer Blood backs up into the lungs and causes pulmonary signs What are the manifestations of left-sided heart failure? - Correct answer Dyspnea, orthopnea, crackles/wheezing, cough, decreased oxygen saturation What are health promotion tips for a healthy heart? - Correct answer Increase fruit and vegetable intake, avoid salt and trans fat foods, exercise 30 minutes/day 5xs/week, healthy weight for height What is acute coronary syndrome? - Correct answer Unstageable angina and myocardial infarction What are the manifestations of acute coronary syndrome (MI)? - Correct answer Indigestion feeling, nausea, vomiting, dizzy, flushing, perspiration, palpitations, fatigue, Dyspnea

What are types of subjective questions that you would ask during a peripheral vascular exam? - Correct answer Any leg pain or cramps, skin changes on arms/legs, swelling of arms/legs, lymph node enlargement, medication, smoking history What assessments would you do during a peripheral vascular exam? - Correct answer Clubbing, capillary refill, pulse, modified Allen test, hair distribution, palpate temperature, test for edema, color changes, DVT risk What is the Wells Score used to identify? What do the scale ratings mean?

• Correct answer Assess DVT risk 1-2= moderate risk 3+= high risk What is the modified Allen test and what is a normal reading? - Correct answer Occlude ulnar and radial arteries while person makes a fist, the color should return in less than seven seconds Give a nursing diagnosis for lymphedema - Correct answer ineffective peripheral tissue perfusion What are relieving factors for venous insufficiency? - Correct answer Elevation, flying, walking, pain medication What are the manifestations of varicose veins? - Correct answer Aching, calf heaviness, restless legs, burning, throbbing, cramping, dilated/tortuous veins, new ones sit on the surface of muscle or bones and old ones are deep and feel spongy What are the manifestations of a DVT? - Correct answer Sudden onset of intense/sharp deep muscle pain, increased warmth, swelling, redness, dependent cyanosis is mild to absent, tender to palpation Where are the complications of a DVT? - Correct answer Clot travels and increases the risk of a pulmonary embolism What are the risk factors for DVT? - Correct answer Immobility, prolonged bed rest, history of varicose veins, trauma, infection, cancer, obesity, heart failure, estrogen use

What are the three mechanisms of venous return? - Correct answer - Skeletal muscle contraction milks blood proximally towards heart -pressure gradient by breathing (inspire=decreased thoracic pressure and increased abdominal pressure) -Intraluminal valves to prevent backflow What is the risk of atherosclerosis? - Correct answer Plaque development in arteries What are the manifestations of chronic venous disease? - Correct answer Edema, varicosities, weeping ulcers at ankles What is the grading scale of Edema? - Correct answer 1+: mild pitting, slight indentation, no perceptible leg swelling 2+: moderate pitting, indentation rapidly subsides 3+: deep pitting indentation remains for a short time, legs look swollen 4+: very deep pitting, indentation last a long time, leg is grossly swollen and distorted What are the manifestations of chronic arterial disease? - Correct answer Low ankle brachial index, cool/pale skin, diminished pulses, pallor on elevation What are the manifestations of acute arterial disease? - Correct answer Pain, pallor, pulselessness, paresthesia, Poikilothermia (cold), paralysis What are the peripheral vascular changes in an aging adult? - Correct answer Blood vessels grow more rigid (arteriosclerosis), calf vein enlargement, decreased number and size of lymph nodes, increased risk of DVT and MI What are the assessment findings associated with abdominal distention: obesity? - Correct answer Uniformly rounded, sunken umbilicus, normal bowel sounds, tympany, scattered dullness over adipose tissue, palpation may be hard to feel through thick abdominal wall What are the causes of hypoactive bowel sounds? - Correct answer Peritonitis, late bowel obstruction, pneumonia, abdominal surgery

What are the causes of hyperactive bowel sounds? - Correct answer Early bowel obstruction, gastroenteritis, brisk diarrhea, laxatives, subsiding paralytic ileus What are the diagnostic results associated with an intestinal/bowel obstruction? - Correct answer Dehydration, possible sepsis, loss of electrolytes, fluid/gas accumulation in bowel above (proximal) obstruction. What are the physical exam findings associated with intestinal/bowel obstruction? - Correct answer Restless, ill appearance, distention, hyperactive bowel sounds early, hypoactive bowel sounds late, tenderness on palpation, hypovolemic shock from dehydration What are the manifestations of an intestinal/Bowel obstruction? - Correct answer Abdominal surgery history with adhesions, vomiting, fever, absent stool/gas, colicky pain from strong peristalsis above obstruction, distention, hyperactive bowel sounds early, hypoactive bowel sounds late, tenderness, hypovolemic shock from dehydration What are positive Murphy's sign indications? How do you test for it? - Correct answer Pain when palpating the liver means gallbladder is inflamed cholecystitis, hold fingers under liver border and ask patient to take a deep breath. Normal=no pain. Positive=sharp pain that indicates cholecystitis What does involuntary rigidity mean? - Correct answer Bored like a hardness of muscles. Protective mechanism for acute peritonitis. Unilateral What does voluntary guarding mean? - Correct answer Occurs when a patient is cold, tense, or ticklish.Bilateral. Feels muscles relax on exhale What are the early manifestations of rheumatoid arthritis? - Correct answer Weakness, redness, joint swelling, heat, pain What are the light manifestations of rheumatoid arthritis - Correct answer Anorexia, weight loss, ulnar drift, swan neck, boutonniere deformity What is spinal deformity's associated with osteoarthritis? - Correct answer Kyphosis

What are the risk factors for osteoporosis? - Correct answer Post menopausal white women, smaller height and weight, younger age at menopause, lack of physical activity, lack of estrogen What is cranial nerve one and how do you assess it? - Correct answer Olfactory S: eyes closed and place familiar smells under the nose and see if it's identified by patient. Not routinely assessed What is cranial nerve two and how do you assess it? - Correct answer Optic S: test visual acuity and field by using ophthalmoscope to examine ocular fundus to determine color, size, shape of optic disc What is cranial nerve three and how do you assess it? - Correct answer Oculomotor M: use penlight to assess people are construction. PERRLA. Assess CN 3,4,6 together What is cranial nerve for and how do you assess it? - Correct answer Trochlear M: move eyes down to the tip of nose. Six Cardinal fields of gaze What is cranial nerve six and how do you assess it? - Correct answer Abducens M: moves eyes to the sides. Six cardinal fields of gaze What is cranial nerve five and how do you assess it? - Correct answer Trigeminal B: palpate masseter muscle and have patient clenched teeth (M). Have patient close their eyes and touch cotton ball on forehead, cheeks, chin bilaterally (S). What is cranial nerve seven and how do you access it? - Correct answer Facial B: have patient smile, frown, puff cheeks, raise eyebrows What is cranial nerve eight and how do you assess it? - Correct answer Acoustic/vestibulocochlear S: voice whisper test What are cranial nerves 9 and 10 and how do you assess them? - Correct answer CN 9: Glossopharyngeal B & CN 10: Vagus B: stick tongue out and say AHH note uvula and soft palate rise midline. Ask patient to swallow What is cranial nerve 11 how do you assess it? - Correct answer Spinal accessory M: have patient shrug shoulders and turn head to the right and left while applying resistant.

What is cranial nerve 12 and how do you assess it? - Correct answer Hypoglossal M: have patient say "light, tight, dynamite" What are the highest and lowest scores of Glasgow coma scale and what do they indicate? - Correct answer Highest score=15: fully alert and oriented Lowest score=3: anything below 6 is coma What are the three categories of Glasgow coma scale? - Correct answer Eye-opening response, motor response, verbal response What does FAST stand for? - Correct answer Face drooping, arm weakness, speech difficulty, time to call 911 What are the manifestations of a UTI in older adults? - Correct answer Communication problems, confusion, lethargy What are the manifestations of urinary retention? - Correct answer Dysuria, nocturia, suprapubic pain, gross hematuria What are the manifestations of benign prosthetic hypertrophy (BPH)? - Correct answer Urinary frequency, urgency, hesitancy, straining to urinate, weak stream, sensation of incomplete emptying, nocturia, symmetric nontender enlargement, prostate feel smooth/rubbery/firm like a nose What are the risk factors for a stroke? - Correct answer High blood pressure, cigarette smoking, cardiac disorders What are the manifestations of a hemorrhagic stroke? - Correct answer Sudden/severe headache, nausea, vomiting, sudden LOC, focal seizures What are the manifestations of an ischemic a stroke? - Correct answer Unilateral face droop, arm drift, weakness or paralysis on one side of the body, difficulty speaking or understanding speech, confusion, sudden onset of dizziness, loss of balance, cloudy vision What are the causes of an ischemic? What are the two types and their causes? - Correct answer -Sudden loss of blood flow to the brain. -

Thrombotic results from atherosclerosis. -Embolic caused by a traveling clot. What is the cause of a hemorrhagic stroke? - Correct answer Caused by a rupture and bleeding from a weakened artery in the brain How do you perform the Rhomberg test? - Correct answer Have patient stand with feet together and arms by their side with eyes closed for 20 seconds. Nurse should monitor while counting for 20 seconds and stand with arms around the patient with a gap between them. What is indicated by a positive Rhomberg test? - Correct answer More than normal swaying