Nurs 112- Test One Practice

Goals should SMART

'Specific' refers to who, what, when, where and why. 'Measurable' means that you can actually measure and evaluate the progress of that goal in a concrete way. 'Action-oriented' means there are actions that can be taken to reach the goal. 'Realistic' includes the ability to work on the goal, having the resources, attitudes, abilities and skills to reach this goal, and how realistic it is to coming to fruition. Finally, 'Timely' means that there is an end time frame or date at which the goal is going to be evaluated.

Formula for converting Farenheit to Celsius (example 102 F)

(102 - 32) x 5/9 = (70x5) / 9 = 39 C

Formula for converting Celsius to Farenheit (example 39 C)

(39 x 9/5) + 32 =(351/5) + 32 = 102F

When should I measure vital signs?

1. On admission to hospital 2. At beginning of shift for inpatients 3. At visit to clinic 4. Before, during, after surgical procedures 5. Whenever patient's condition changes

Normal BP Range

100-119 mm Hg systolic/60-80 mm Hg diastolic

Average BP

110/70 mmHg

Normal Respiration Range

12-20 breaths per minute

Prehypertensive BP Range

120-139 mm Hg systolic/60-80 mm HG diastolic

Normal Pulse Range

60-100 bpm

Average Pulse Rate

80 bpm

Average normal temp in Adult - Oral

98 F 36.7 C

Average normal temp in Adult - Rectal

98.6 F 37 C

Circadian rhythm

A cyclical repetition of certain physiological process that occurs ever 24 hours causing fluctuation in body temp by 1 or 2 degrees F. Usually lowest in early morning an highest in early evening.

The nurse would attempt to gather which of the following information while obtaining a health history from the client? Select all that apply. A. Who lives with the client and the client's support systems. B. Annual household income. C. Client's use of vitamins and herbal supplements D. History of past illness and surgeries E. Religious preference beliefs that might relate to health care issues

A,C,D,E Rationale: The nurse focuses on physical, psychosocial, and spiritual concerns in obtaining information in the health history. The nurse would want to obtain information on any medications or nutritional supplements the client is using the health history interview. The client's past medical history is a primary focus of the health history. The nurse seeks to obtain data from the client using a holistic approach. The nurse focuses on physical, psychosocial, and spiritual concerns. Information regarding a client's personal finances is not appropriate or necessary to inquire about in the interview.

The nurse would use which method of examination to assess for the presence of a bruit in the abdomen? A. Auscultation B. Percussion C. Palpation D. Inspection

A. Auscultation Rationale: Auscultation uses the same hearing to identify sounds that are normal and abnormal during the assessment. A bruit is an abnormal sound in a blood vessel that is only detectable by listening with a stethoscope. A bruit is an abnormal sound audible only with auscultation. The turbulent blood flow that is heard as a bruit might be palpated as a thrill. A bruit cannot be seen but is heard; thus, it could not be detected on inspection.

Prior to taking the health history, the nurse should do which of the following? A. Establish a rapport with the client B. Offer the client a beverage of choice C. Establish that insurance coverage exists D. Ask the client to disrobe and put on a gown

A. Establish a rapport with the client Rationale: In order to gain as much insight and information from the client as possible, the nurse should establish a level of trust or rapport with the client. The client will be able to relax and answer questions if he or she is asked in a nonthreatening manner. Offering the client food and drink is not appropriate. The nurse has no need to gather information about insurance or finances since other personnel have already done this in the admissions process. The client does not need to wear an examining gown to answer questions and is not likely to be comfortable doing so.

What action should the nurse take to increase the likelihood of obtaining quality data when doing a complete physical assessment? A. Provide adequate lighting and a comfortably warm room for the interview B. Outline the process in detail prior to beginning the examination C. Ask all family members or significant others to wait outside the room. D. Identify each piece of equipment used with the appropriate medical term.

A. Provide adequate lighting and a comfortably warm room for the interview Rationale: a comfortable environment puts the client at ease and increases the likelihood that nurse will be able to maintain necessary data. The approach may overwhelm the client and increase anxiety. The family may be able to provide additional data through the assessment process, and their presence may be reassuring to the client. As the nurse proceeds with the more intimate components of the assessment, the family may be asked to leave. Inform the client immediately prior to assessing each system (rather than before than before the examination) what is entailed to facilitate understanding. Using terminology the client can understand is always appropriate

Hyperthermia

Abnormally high body temperature 1. Heat stroke 2. Heat exhaustion Associated with overexposure to high temperatures and inadequate fluid replacement - the body loses the ability to sweat and is unable to cool down.

A client who is alert and responsive was admitted directly from the provider's office with a diagnosis or "rule out acute myocardial infarction." Of the following alterations found on the initial assessment, which is the greatest concern of the nurse? A. Blood pressure supine 138/76 B. Respirations are 28 and labored C. Temperature is 99.8°F D. There are infrequent missed apical beats

B- Respirations are 28 and labored Rationale: Using the principles of the ABC's (airway, breathing, and circulation), an alteration in respiration is always a primary concern. A disturbance in normal ventilation (normal rate= 12-20) may be occurring secondary to the medical diagnosis of myocardial infarction, but labored respirations from any sure would be a cause of immediate concern. The blood pressure remains in an acceptable range. The slight temperature elevation is likely related to the overall inflammatory response of the body but is not a cause for immediate concern. Infrequent abnormalities of cardiac rhythm are common and should only be of concern when appearing frequently or with longer duration.

Before palpating the abdomen during an assessment, the nurse should perform which of the following actions? A. Put on sterile gloves B. Auscultate bowel sounds C. Elevate the client's head D. Percuss all 4 quadrants

B. Auscultate bowel sounds Rationale: before palpating the abdomen, the nurse should first listen to all 4 quadrants for bowel sounds. It is unnecessary to use sterile gloves unless there is an open wound or lesion. The client should be in a supine position if tolerated by the medical condition. Palpating and percussing the abdomen first can alter bowel sounds, making auscultation less reliable.

The nurse would document which of the following in the medical record as objective data obtained during the client assessment? A. Detailed description of pain in an extremity B. Loss of hair on lower legs bilaterally C. Report of numbness of the right hand D. Description of scalp itching, which occurs each occurs each evening

B. Loss of hair on lower legs bilaterally Rationale: objective data can be seen, heard, felt, or smelled during physical examination. The client's sensations, feelings, values, beliefs, and attitudes are regarded as subjective. Subjective data is only apparent to the person affected and can be described or verified only by that person. Itching is an example of subjective data.

A nurse has conducted a physical examination on a client and notes that the thyroid gland is normal. How would the nurse document this in the medical record? A. Thyroid slightly deviated to the left, no nodules, palpated B. Thyroid midline, smooth, with no nodules palpated C. Thyroid midline, with parathyroid glands easily palpated bilaterally D. Thyroid slightly deviated to the right, with pea-sized nodules at the base

B. Thyroid midline, smooth, with no nodules palpated Rationale: The thyroid should be midline, smooth, and free of nodules. The parathyroid glands are too small to be manually palpated. The other two findings are abnormal.

When taking a health history, the nurse should focus on which of the following? A. Completing the process in a timely manner B. Using therapeutic communication skills to identify the client's health care status C. Documenting objective data using the client's own words D. Attempting to have no interrupts from family members who are present

B. Using therapeutic communication skills to identify the client's health care status Rationale: a nurse must focus on using therapeutic communication skills, which will enhance the interview. In addition, the ability to interpret nonverbal communication is paramount in achieving the goals of history taking. The time required to complete the health history is not the nurse's primary focus. The nurse must document carefully, but it is subjective data, not objective, that is recorded using the client's own words. The client or nurse in the interview; in many instances family members are helpful in the process.

BMR

Basic metabolic rate - amount of energy required to maintain the body at rest.

Constant fever

Body temperature fluctuates minimally but always remains above normal.

In order to examine the ocular mobility of a client who recently experienced a stroke, the nurse should examine which of the following cranial nerves? Select all that apply. A. Cranial Nerves I and VII B. Cranial Nerves II and V C. Cranial Nerves III and IV D. Cranial Nerve VI E. Cranial Nerve IX

C & D Rationale: Evaluation of ocular motility provides information about cranial nerves III, IV, and VI; their brainstem connections; and the cerebral cortex. These nerves are responsible for extraocular movements. Cranial nerve I is related to the ability to smell and cranial nerve VII controls some facial movements (but not ocular movement), and cranial nerve V is the trigeminal nerve that controls some facial movements and sensations as well as the ability to clench the jaw muscles. Cranial nerve IX is the glossopharyngeal nerve that controls some tongue movements, swallowing, and taste.

Hypothermia

CDC defines abnormally low core temp as less than 95 F Associated with extended exposure to cold , such as during surgery, extreme weather, cold water immersion, or lack of shelter.

Why do infants where caps at hospital

Cause 30% of their body heat is lost through head and this places them at increased risk of decreased body temperature

Which statement made by the client indicates an understanding of how the nurse will perform the Romberg test? A. "You want me to tell you when I can no longer hear the sound from the tuning fork after you place it on my head." B. "You want me to use my index finger to touch my nose and then your finger as quickly as possible" C. "I am going to walk 5 or 6 steps in a straight line, placing my toes directly behind the heel of my other foot." D. "You want me to stand with my feet together and eyes closed for a short time."

D. "You want me to stand with my feet together and eyes closed for a short time." Rationale: The Romberg test is performed to test motor function. The client is asked to stand with feet together with arms resting at the sides, and then to close the eyes. The nurse watches for the presence of swaying, which is considered normal only if it is only slight. However, if the client cannot maintain foot stance, it is documented as a positive Romberg's sign. Always remember to stand close to the client during this test to prevent falls. Relating cessation of sounds would be appropriate for the Weber test. Although the finger-to-nose test is part of the neurologic exam, it is not the Romberg test. Heel-to-toe walking is also used to assess a client's balance, but it is not the Romberg test.

The nurse would use which technique first when examining the abdomen? A. Palpation B. Auscultation C. Percussion D. Inspection

D. Inspection Rationale: During inspection, the nurse scrutinizes and evaluates by sight any clues of pathology that may be present. By first performing the other assessment techniques (auscultation, percussion, and palpation), the nurse could alter the findings. Percussing the abdomen prior to inspection could alter the findings of the assessment.

Febrile

Person with fever

Afebrile

Person without fever

Fever occurs in response to

Pyrogens, when bacteria or foreign substances invade the body, they stimulate phagocytes (WBCs) which ingest the invaders and secret pyrogens.

What is SAO2

Saturation of Oxygen in hemoglobin

Recurrent fever

Short periods of fever alternating with period of normal temps each lasting 1-2 days

What is BHC ADN program framework (which national competencies are used?)

To exemplify core values that align with the College and the National League of Nursing (NLN): caring, diversity, ethics, excellence, holism, integrity and patient centeredness. To promote Quality Safety Education Nursing Competencies (QSEN) of patient-centered care, teamwork & collaboration, evidence based practice,quality improvement,safety, and informatics.

Remittent fever

Wide range of temperature fluctuations of more than 2 degrees difference over a 24hrs period which are all above normal.

Intermittent fever

a body temperature that alternates at regular intervals between periods of fever and periods of normal or subnormal temperatures

piloerection

hair standing on end

vasoconstriction

narrowing of blood vessels