NUR 245 exam 3

Which clinical finding would the nurse expect when assessing an infant with pyloric stenosis?

-visible peristaltic waves (stomach is attempting to propel its contents through the stenotic pyloric sphincter) -olive-shaped mass in the right upper quadrant

Which korotkoff sound represents the diastolic blood pressure in an adolescent?

Fifth

pulmonary contusion

Injury or bruising of lung tissue that results in hemorrhage.

ascites

abnormal accumulation of fluid in the abdomen

What is the significance of feeling for the radial pulse?

assess the heart rate

What is the significance of feeling for the popliteal pulse?

assesses popliteal aneurysms and peripheral vascular disease

hemothorax

blood in the pleural cavity

Which info would the nurse include in his/her teaching for a class on breast health?

breast awareness will help a client know if there are changes in her breasts

pathological

due to disease

Which assessment would the nurse report to the primary HCP because it likely indicates pyloric stenosis?

peristaltic waves that traverse the epigastrum -projectile vomiting -bowel activity is min. because little of the feeding passess thru pyloric sphincter NO loud bowel sounds

What is the 1st Korotkoff sound?

sharp sound, represents systolic pressure

Which instruction would the nurse give to a client who will be scheduling a mammogram?

"each breast will be firmly compressed between 2 plates" -test shoulld be sched 2 weeks after menses (when breasts are least sensitive), mammography is more accurate in postmenopausal women

Which client statements indicates risk for breast cancer?

-"first child was born when I was 32" -"noticed a slight discharge from a nipple" -"I consume 2-4 glasses of alc/day" after the age of 30 y/o, discharge is an early symptom, early onset of menarche, consumption of 2-4 glasses of alc

Which clinical manifestation would the nurse expect to find when assessing a client who is 8hrs postop creation of a colostomy?

-Absence of drainage from colostomy -bowel sounds will be absent until peristaltic activity returns -stoma should be bright cherry red

nurse administers an older clients medications via gastrostomy tube in long term care setting. Which finding would necessitate holding the feedings and medications and notifying the healthcare provider immediately?

-abscence of bowel sounds -presence of abdominal distention -residual capacity exceeding 300 mL -Positive guaiac test of abdominal contents (indicates bleeding) -seepage of feeding around tracheostomy

Which action would the nurse take for a client whose right radial pulse is weak and thready?

-assessing all peripheral pulses -assessing and comparing both radial pulses -asking a second nurse to assess clients pulses -assessing for edema or other issues that may be restricting peripheral blood flow -observing for pallor/skin temperature differences distal to the weak pulse

When would the nurse observe a client to assess their level of functioning?

-during mealtime -when preparing medication -when administering insulin injections observation of the functional level of the client often occurs during return demonstration

The nurse is obtaining a history and performing a physical assessment of a client with cancer in the tongue. What clinical findings would the nurse expect to identify?

-leukoplakia: (thick, white patches on the inside surfaces of your mouth) -alterations in taste -enlarged cervical lymph nodes

Which action by the nurse is a priority in the immediate postoperative period after splenectomy?

-monitor heart rate -take blood pressure -check urine output -auscultate lung sounds (postop atelctasis is common after abdominal surgery) -look for abdominal distention

Risks of developing breast cancer?

-over 60 y/o -pos. family history of breast cancer -no children -menopause at a later age

The nurse is caring for a client with a bowel obstruction. What assessment findings indicate possible onset of peritonitis?

-rebound tenderness -diminished bowel sounds -rigid, board-like abdomen -client will experience constipation

Which goal is appropriate when treating anorexia nervosa?

-repairing of family interactions -reinstitution of normal nutrition to counteract a state of malnutrition -correction of deficits and distortions in psychological functioning via pscyhotherapy

In which order would the nurse perform the actions when inspecting the chest of a client with a suspected heart attack after a fire?

1. Inspect the chest for paradoxical chest movements 2.Palpate the sternum, clavicles, and ribs 3. Auscultate the breath sounds and heart sounds 4. Evaluate client for rib fractures, pulmonary contusion, blunt cardiac injury, and hemothorax 5.obtain a chest x-ray and 12-lead electrocardiogram (ECG)

Which korotkoff sound represents the diastolic blood pressure in toddlers?

Fourth -fourth kortkoff sound is muffled and low

ascites treatment

Is to administer Albumin, it pulls fluids back to the vascular space

substernal area

Pain felt just behind or below the sternum -pressure/heaviness of chest Some of the most common causes of sternum and substernal pain are: costochondritis. clavicular (collarbone) injuries and fractures.

The nurses assess bilateral +4 peripheral edema while assessing a client with heart failure and peripheral vascular disease. Which is the pathophysiological reason for excessive edema?

Shift of fluid into interstitial spaces -Edema is defined as accumulation of fluid in interstitial spaces

hypoactive bowel sounds

diminished or absent bowel sounds signal decreased motility as a result of inflammation as seen with peritonitis; from paralytic ileus as following abdominal surgery; or from late bowel obstruction. Also occurs with pneumonia.

What is the significance of feeling for the ulnar pulse?

evaluating arterial insufficiency

Which is not a potential nutritional risk in pregnancy?

hypertension -diabetes, use of tobacco, frequent pregnancies is a nutritional risk in pregnancy

Which pathophysiological rationale explains why a client who is 4 days postabdominal surgery has not passed flatus and has hypoactive bowel sounds and why a paralytic ileus is suspected of developing?

impaired neural functioning

peritonitis

inflammation of the peritoneum (membrane lining the abdominal cavity and surrounding the organs within it)

flatus

intestinal gas

pyloric stenosis

narrowing of the opening of the stomach to the duodenum

What is the significance of feeling for the brachial pulse?

note the blood pressure

paralytic ileus

occurs when neurological impulses diminish and is a result of anesthesia, infection, surgery

Which action would the nurse take to assess for ascites?

percuss the clients abdomen and listen for dull sounds

Which instruction would the nurse provide to a client who would like to learn breast self examination?

squeeze the nipples to examine for discharge -serous/bloody discharge from nipple is pathological and must be reported

Which is an abnormal finding of the urinary system?

when striking the area, pain in the flank region is felt by the client