NUR 220A Final Exam
Toddler: Suggested Communication Approach
- Stay calm - get on their level - approach guardian first - use their language - books and play - approach cautiously - explain as you go
Preschool: Emotional Development
- Tantrums - clear limits and boundaries - learn to cooperate - imitation - strive for independence - attention-seeking behavior - time/quantity/space - imagination
Toddler: Emotional Development
- Thrive on routine - Try to be independent - Parallel play - Separation anxiety peaks - Security item(s) - They don't like people who aren't their people
Barlow-Ortolani maneuver
- To detect hip dislocation in newborn - performed on every child in newborn nursery to assess hip dislocation what you'd hear if positive for barlow-ortolani: clicking or rough movement you want a NEGATIVE barlow-ortolani
Adolescent: Cognitive Development
- abstract reasoning - logical thinking - 60 minute attention span
mobility - past health history
- accidents/trauma/surgery to bones/joints/muscles - any residual issues from accidents/trauma/surgery
Plantar Grasp reflex
- birth to 7-9 mo. - stroke ball of foot - RESPONSE: toes curl around object stroking foot If persists, it will interfere with: - Ability to stand with feet flat on surface - Balance reaction and weight shifting in standing - MUST BE integrated BEFORE walking occurs
mobility - present health status
- chronic diseases can affect mobility and ability to do ADLs - many meds for musculoskeletal diseases can have adverse effects and increase risk of injury
School-Age: Emotional Development
- close friendships - increased cooperation
School-Age: Language development
- conversation is constant - more words
what are different types of nursing diagnoses
1. problem focused nursing diagnoses 2. risk nursing diagnoses 3. health promotion nursing diagnoses
what are the functions of the skin
1. protect body from microbial, foreign substance invasion, and trauma to internal structures 2. retain body fluids and electrolytes 3. sensory input with the outside words, detects temperature and surface texture 4. produces vitamin D 5. excretes sweat, urea, lactic acid 6. expresses emotion (blushing) 7. repairs itself through cell replacement
what 6 elements are included in the dynamic process of communication
1. referent 2. sender 3. receiver 4. message 5. channel 6. feedback
what are the essential components of professional nursing communication
1. respect 2. assertiveness 3. collaboration 4. delegation 5. advocacy
what are the patient positions for examination
1. sitting 2. supine 3. dorsal recumbent 4. lateral recumbent 5. lithotomy 6. sims 7. prone 8. knee-chest
the musculoskeletal system does 4 important things:
1. support and mobility for body 2. protection for internal organs 3. produces blood cells 4. stores minerals - calcium and phosphorus
how are joints classified
1. type of material 2. degree of movement
what are some common senses problems
1. vision difficulties 2. hearing loss 3. tinnitus 4. earache 5. epistaxis 6. mouth lesions 7. changes in sensation
what are two types of verbal communication
1. written communication 2. electronic communication
which age group has the following fine motor skills: beginning thumb-finger grasping, releases object at will, grasps for toys out of reach
8 month old
which age group has the following gross motor skills: sits securely without support, bears weight on legs when supported, may stand holding on
8 month old
Toddler Blood Pressure
80-112/50-80
toddler BP
80-112/50-80
School-Age Blood Pressure
84-120/54-80
school age child BP
84-120/54-80
old-old
85 years and older
Toddler Heart Rate
90-140
toddler HR
90-140
WBC for newborns
9000-30000
Adolescent Blood Pressure
94-120/62-88
adolescent BP
94-139/62-88
troponin T range
< 0.1 ng/dl
Troponin I range
<0.03 ng/dl
LDL value
<130mg/dl
cholesterol range
<200 mg/dL
HDL for men
>45mg/dl
HDL range for women
>55mg/dl
range of motion: shoulder with elbow fixed, rotate shoulder by moving arm until thumb is turned inward and turned back
internal rotation
explain a comprehensive assessment
interview, health history, review of systems, extensive head to toe assessment
range of motion: foot turn sole of foot medially
inversion
what is nontherapeutic communication
is can be hurtful and damaging to others
it has been around a half an hour since youve administered pain medication to a patient, what should you do
re-evaluate the patient. whenever you give medication for pain, re-evaluate the pt and make sure the medication is working like it should
hand off reports
real time processing of passing pt specific info from one caregiver to another
describe cultural sensitivity
recognition of the often pronounced differences among cultures
the ___ and ____ make up the end of the gastrointestinal tract and are considered to be included in the perineal structures
rectum and anus
lateral recumbent
recumbent position that aids in detecting heart murmurs. poorly tolerated patients with respiratory difficulties
dorsal recumbent
recumbent position that promotes relaxation of abdominal muscles, best for abdominal assessment
erythema in light skinned patients
reddish tone with evidence of increased skin temperature secondary to inflammation
what are some theoretical underpinnings of critical thinking
reflection, evidence, standards, and attributes or traits
what do eccrine sweat glands do
regulate body temperature by water secretion through the surface of the skin; found in palms of hands, soles of feet, and forehead
what is ovulation
release of an ovum (egg); occurs as part of the monthly menstrual cycle
what is feedback
response of the receiver
what are common problems associated with joints
rheumatoid arthritis, osteoarthritis, bursitis, and gout
low pitched, coarse, loud, low snoring or moaning tone, cough may clear
rhonchi
explain subjective data
spoken info or symptoms difficult to validate, should be documented as direct quotations from pt
nasal speculum
spreads opening of nares
vaginal speculum
spreads vaginal canal for pelvic exam
poor posture can decrease respiratory
status
state the infantile reflex: infant held upright with feet flat on surface, infant will pace alternating steps
step in place
upper ribs are connected to the ____ by cartilage
sternum
fetoscope
stethoscope for a fetus
stretch marks
striae
explain the direct percussion technique for a physical assessment
striking a finger/hand directly against pts body
Root Reflex
stroke cheek resulting in infant turning head to side and opening mouth 2-4 mos Helps baby find food
what are the elements of SOAP
subjective data, objective data, assessment, plan
what are the elements of SOAPIE
subjective data, objective data, assessment, plan, intervention, evaluation
state the infantile reflex: touching object against ulnar side of infants hand and then placing finger in palm of hand, infant should grasp the finger and should be tight
palmar grasp
The public health nurse presents a program on breast self-examination. After a return demonstration, the nurse concludes that she needs to review certain aspects of the teaching program. Which behavior by one of the students supports this conclusion? 1. palpating each breast while in the sitting position 2. checking her breasts for any deviation from what is expected 3. palpating each breast with the palmar surface of her extended fingers 4. checking her breasts for symmetry while holding her arms above her head
palpating each breast while in the sitting position
paraplegia
paralysis from the waist down
quadriplegia
paralysis of all four limbs
hemiplegia
paralysis of one side of the body
preventive measures should be taken immediately if the patient is at risk for developing this skin integrity problem
pressure ulcer
what are the types of data collection
primary data secondary data subjective data objective data
what are the elements of PIE
problem, intervention, evaluation
past medical history
problems with lungs respiratory diseases injury/surgery
range of motion: forearm turns lower arm and hand so palm is down
pronation
menstrual cycle: stage 2
prostmenstrual or preovulatory phase - days 5-12 follicle stimulating hormone (FSH) stimulates hair growth; ovary and maturing follicle produce estrogen which supports egg development
Health Insurance Portability and Accountability Act (HIPAA)
protection of personal health information (PHI)
goniometer
protractor type device that determines degree of flexion or extension
the most commonly reported skin condition is ______
pruritus (itching)
public communication
public forums
bleeding under the skin
purpura
itching
purritis
containing pus; green drainage
purulent
Open-ended questions
questions that allow respondents to answer however they want
range of motion: wrist bend wrist medially towards thumbs
radial flexion
state the infantile reflex: touch the infants lips and the sucking motion should follow with lips and tongue
sucking
range of motion: forearm turns lower arm and hand so palm is up
supination
advocacy
supporting the interest of others
the neurological assessment for infants and newborns
symmetrical head, circumference measured, awareness of anterior and posterior fontanelles and palpation of fontanelles cranial nerves used: 2, 4, 5, 6, 7, 8, 9
the neurological assessment for toddlers and children
symmetry in head and check all cranial nerves except for smell
what is subjective data
symptoms, from patient
how do you perceive pain in a toddler
tantrum, holding where it hurts, rocking, and pursed lips
Crawling reflex
when placed on abdomen, infant will make crawling movements with the arms and legs until about 4 weeks old Helps baby find mother and food
what does guarding mean
when you do to palpate a location and the patient pulls back and away from you. this indicates it is a painful area for the patient
accountability
willingness to accept responsibility for ones actions
monofilament
wire like device used to test for sensation
in terms of gender, who complains more about pain
women. women complain more about pain while men are more stoic about pain
what is nonverbal communication
wordless transmission of information
disruptions in the skins integrity that lead to a loss of the skins normal functioning
wound
jaundice in light skinned patients
yellowish color of the skin, sclera of eyes, fingernails, palms of hands, and oral mucosa
jaundice in dark skinned patients
yellowish-green color most obviously seen in sclera of eye (do not confuse with yellow eye pigmentation), palms of hands, and soles of feet
tissue integrity - toddlers/children
• Expected Findings - Skin • Smooth with consistent color and no lesions • Bruising is common on the lower legs • Skin turgor - same as adult
reproduction - laboratory tests
•Amniocentesis - used to detect birth defects •MSAFP - alpha fetal protein (assessing for trisomy 21, trisomy 18, neural tube defects) - performed 16-18 weeks of gestation
tissue integrity - wounds
•Assess if explanation matches discoloration •Poor wound healing can indicate underlying issues •Decreased BP can alter skin - hair distribution, temperature,
reproduction - past health history
•Benign changes (cysts) or breast cancer (increased risk of recurrence) •Cysts make it difficult to detect breast cancer - already lumpy •History of ovarian/endometrial/colon cancer - increase breast cancer risk •Breast surgery •Age at first menstruation •Pregnancy history (no children or first after age 30 is increased risk of breast cancer)
reproduction - family history
•Breast cancer
justice
fairness
School-Age Heart Rate
75-100
school age child HR
75-100
middle-old
75-84
calipers for skinfold thickness
estimates body fat
what are the female sex hormones
estrogen and progestin
range of motion: fingers straighten fingers
extension
range of motion: hip moving leg back beside other leg
extension
range of motion: knee returning heel to floor
extension
auscultation of lung sounds anteriorly--one should assess how many locations??
8 locations
range of motion: neck and cervical spine returning head to erect position
extension
range of motion: shoulder return arm to position at side of body
extension
clinical judgment
combines critical thinking and reasoning and repetitive decision making skills of a nurse
range of motion: thumb moving thumb straight away from hand
extension
range of motion: toes straighten toes
extension
range of motion: wrist moving fingers, hand, and forearm into same place
extension
what is the spiritual assessment tool
faith, importance, community, apply and address (FICAA)
the ________ capture and draw ova into the tube for fertilization
fallopian tubes
Facilitation
"Go on" and "Uh-huh"
Meaning of the Symptoms to the patient
"How has it affected your life?" "Why have you sought care now?" "What do you think may be the cause?"
Quantity
"How often do you have this feeling?" "How bad is it?" "On a scale of 0-10 rate your pain."
Quality
"What does it (feel, look) like?"
Aggravating or Alleviating Factors
"What make it better/worse?" "Is there any activity that seems to cause it?" "What have you done for it?" "Did it help?" "Was there some reason you didn't do anything about it?"
Associated Manifestations
"What other things do you see of feel when it occurs?" "Has it affected your appetite/elimination/sleeping?"
Chronology
"When was the first time it occurred?" "Any particular time of day, week, month, or year?"
Setting
"Where are you when this occurs?" "What are you doing when this happens?"
Location
"Where do you feel it?" "Where is it located?"
Toddler: Cognitive Development
- 3-5 minute attention span - experiment.explore - learning through objects - cause and effect
Adolescent: Language Development
- Adult-level language - selective choosing
School-Age: Suggested Communication Approach
- Answer the questions - medical play - allow patient interaction - set up limits and consequences - stickers! - prepare 1-5 days in advance
Infant: Suggested Communication Approach
- Approach guardian first - slow & calm - Be responsive - Read where the patient is - Speak on their level/teach conversation - explain as you go
Preschool: Suggested Communication Approach
- Bandaids - play - offer choices - simple sentences - puppets (engagement) - short explanations - explain as you go/short time gap - talk to guardian first
Infant: Emotional Development
- Completely dependent - Separation anxiety - Sleep - Love/interaction - Security - Responsive to their environment
Preschool: Language Development
- Short/full sentence - lots of vocab - repetition - start to use grammar and pronouns
mobility - personal/psychosocial history
- exercise - smoking (inhibits bone growth) - sports (weekend warrior) or repetitive work injury (push/pull/lift), protection (stretching, helmets vs proper body mechanics)
Adolescent: Suggested communication approach
- give them as many choices as possible - talk to them like an adult - learn their interests - try to collaborate - prepare up to a week before - respect their privacy
overall mobility inespection
- inspect axial skeleton for symmetry and alignment - inspect muscles for size and symmetry - observe gait for conformity, symmetry, and rhythm - observe any use of assistive devices
School-Age: Cognitive Development
- interested in learning - start to make rules to games - rule oriented - concrete thinking - start to understand conversation - 10-30 minute attention span
Preschool: cognitive development
- kids only see the world from their perspective - 5-10 minute attention span - abstract thinking - time/quantity
mobility - family history
- vertebral disorders and arthritis
Adolescent: Emotional Development
- very emotional - don't want to be different/weird - question authority - privacy - want independence - responsibility for their actions - competition
Bilirubin
0.3-1.0
creatine range for female
0.5-1.1
creatine range for males
0.6-1.2
normal INR range
0.8-1.1
A client with heart failure has anxiety. Which effect of anxiety makes it particularly important for the nurse to reduce the anxiety of this client? 1. increases the cardiac workload 2. interferes with usual respirations 3. produces an elevation in temperature 4. decreases the amount of oxygen
1
A nurse is palpating the lymph nodes of an 18-month-old toddler and finds enlarged postauricular and occipital nodes. What is the significance of this finding? 1. This is a normal finding at this age. 2. The toddler may have an ear infection. 3. The toddler may have an inflammation of the scalp. 4. The toddler needs to be referred to a pediatrician.
1
A nurse notices cyanosis in a client with heart disease. Which site would the nurse assess to confirm cyanosis? 1. lips 2. sclera 3. conjunctiva 4. mucus membrane
1
During inspection of the mouth of a 72-year-old male patient, the nurse notices a red lesion at the base of his tongue. What additional information does the nurse obtain from this patient? 1. Alcohol and tobacco use 2. Date of his last dental examination 3. How well his dentures fit 4. A history of gum disease
1
Each patient has had consistent blood pressure readings during the last three clinic visits. Which patient has a blood pressure consistent with expected findings? 1. Mr. P, whose blood pressure has been 110/78 2. Ms. J, whose blood pressure has been 140/90 3. Mr. Q, whose blood pressure has been 130/76 4. Ms. Y, whose blood pressure has been 120/80
1
Narrowing of the bronchi creates which adventitious sound? 1. Wheeze 2. Crackles 3. Rhonchi 4. Pleural friction rub
1
On auscultation of a patient's lungs, the nurse hears a low-pitched, coarse, loud, and low snoring sound. Which term does the nurse use to document this finding? 1. Rhonchi 2. Wheeze 3. Crackles 4. Pleural friction rub
1
The nurse is caring for a client who is experiencing signs and symptoms of a cardiac dysrhythmia and is scheduled to wear a Holter monitor for 24 hours. What should the client should be instructed to do during the test? 1. keep a diary of activities 2. stay away from microwave ovens 3. avoid taking any nitroglycerin that day 4. take both blood pressure and pulse every 2 hours
1
The nurse palpates the abdomen to gather data about which organs located in the right upper quadrant? 1. Liver and gallbladder 2. Stomach and spleen 3. Uterus, if enlarged, and right ovary 4. Right ureter and ascending colon
1
what are formats of POMR
1. PIE 2. APIE 3. SOAP 4. SOAPIE 5. SOAPIER 6. DAR 7. CBE
To prepare a client for surgery, which explanation by a nurse would be accurate related to pneumatic compression devices? 1. they help the venous blood return to the heart 2. they will not cause discomfort, but gently massage the legs 3. they are used instead of anticoagulant therapy 4. they must be worn until the first time the client gets out of bed
1
What does the nurse assess for during each prenatal visit? 1. Blood pressure 2. Hemorrhoids 3. Personal habits (smoking, alcohol consumption) 4. Visual acuity
1
What would be an abnormal finding for a 7-year-old African American boy? 1. Abdominal distention 2. Umbilical hernia 3. Abdominal breathing 4. Tenseness of abdominal muscles
1
Which finding on a 2-month-old baby is considered abnormal and requires further follow-up? 1. The anterior fontanelle is not palpable. 2. The thyroid gland cannot be palpated. 3. The head circumference is slightly greater than the chest circumference. 4. Head lag is observed when the shoulders are lifted off the examination table.
1
Which would be an abnormal finding during an abdominal examination of an older adult? 1. Report of incontinence when sneezing or coughing 2. Loss of abdominal muscle tone 3. Bowel sounds every 15 seconds in all quadrants 4. Silver-white striae and a very faint vascular network
1
what are the types of bones in the cranium
1 frontal 2 parietal 2 temporal 1 occipital
which age group has the following fine motor skills: follows with eyes to midline, hands predominantly closed, strong grasp reflex
1 month old
which age group has the following gross motor skills: turns head to side, keeps knees tucked under abdomen when pulled to sitting position, has gross head lag and rounded, swayed back
1 month old
The nurse is performing an abdominal assessment. What assessment techniques should be included in the assessment? Select all that apply. Inspection Percussion Palpation Illumination Auscultation Mirror check
1,2,3,5
The school nurse is performing a hearing screening for an adolescent. The primary focus of a history and examination for this age group would be: Select all that apply. explore exposure to loud noises, including music. perform the whisper test. examine the ear canal with an otoscope. perform screening tests for hearing loss. ask about previous antibiotic use.
1,2,4,5
infant
1-12 months
toddler
1-3 years
A 24-hour urine test is prescribed for a client who has a tentative diagnosis of pheochromocytoma. What should the nurse do first? 1 Start the time of the test after discarding the first voiding. 2 Discard the last voiding in the 24-hour time period for the test. 3 Insert a urinary retention catheter to promote the collection of urine. 4 Strain the urine following each voiding before adding the urine to the container.
1.
A client is scheduled for a colonoscopy, and the healthcare provider prescribes a tap water enema. In which position should the nurse place the client during the enema? 1 Left Sims 2 Back lying 3 Knee chest 4 Mid-Fowler
1.
The nurse is caring for a client who had a hip replacement 2 days prior. After removing a bedpan from under the client, what is a priority nursing intervention? 1 Provide perineal care. 2 Turn and position the client. 3 Give a complete bed bath. 4 Document the bowel movement
1.
The nurse is caring for a client with burns and reviews the client's laboratory results: blood urea nitrogen (BUN), 30 mg/dL (10.2 mmol/L); creatinine, 2.4 mg/dL (184 mcmol/L); serum potassium, 6.3 mEq/L (6.3 mmol/L); pH, 7.1; Po 2, 90 mm Hg; and hemoglobin (Hgb), 7.4 g/dL (74 mmol/L). Which condition does the nurse suspect the client has based upon these findings? 1 Azotemia 2 Hypokalemia 3 Metabolic alkalosis 4 Respiratory alkalosis
1.
The nurse is interviewing a patient with a history of flank pain, fever, chills, and pain radiating to the groin. Which examination technique is most appropriate for this patient? 1. Percussion of the costovertebral angle 2. Deep palpation of the lower abdomen 3. Inspection of a urine specimen 4. Auscultation of the lower quadrants of the abdomen
1.
The nurse is teaching a patient how to evaluate the percentage of fat in a serving of food. She explains that the label on a package of a toaster pastry states that there are 6 g of fat and 210 calories per serving. What is the percentage of fat per serving? 1. 26% 2. 35% 3. 54% 4. 72%
1.
The student nurse is studying the liver. The primary function of the liver is to: 1. metabolize nutrients. 2. store vitamin C. 3. produce red blood cells for circulation. 4. absorb most nutrients.
1.
Which breath sounds are expected over the posterior chest of an adult? 1. Vesicular 2. Bronchovesicular 3. Bronchial 4. Bronchoalveolar
1.
Which finding is considered abnormal during late pregnancy? 1. Watery vaginal discharge 2. Hemorrhoids 3. Lordosis 4. Abdominal striae
1.
Infant: cognitive development
1. Reflex Stage 2. Primary Circular Reactions 3. Secondary Circular Reactions 4. Coordination of Schema - reflexes - observe repetition - intentionally initiate interaction (reaching/pointing) - 1-2 minute attention span
what are techniques for nonverbal communication
1. active listening 2. silence 3. therapeutic touch
5 locations to auscultate for heart sounds
1. apical 2. pulmonary 3. erbs 4. tricuspid 5. mitral
components of health history include
1. biographic data 2. reason for seeking care 3. history of present illness 4. present health status 5. past health history 6. family history 7. personal and psychosocial history 8. review of systems
what are the 8 things you are supposed to cover in a pts health history
1. biographic data 2. reason for seeking care 3. history of present illness 4. present health status 5. past health history 6. family history 7. personal and psychosocial history 8. review of systems
auscultation is a component of which examination technique? 1. blood pressure measurement 2. visual acuity 3. examination of the ears 4. measurement of oxygen saturation
1. blood pressure measurement
what are two types of nonverbal communciation
1. body language 2. voice inflection
what are common neuromuscular problems
1. changes in movement 2. aphasia (dysphasia) 3. dysphagia
what are the intellectual standards of critical thinking
1. clarity 2. accuracy 3. precision 4. relevance 5. depth 6. breadth 7. logic 8. significance 9. fairness
what are the 3 types of physical assessment
1. comprehensive assessment 2. focused assessment 3. emergency assessment
what are the 5 interrelated cultural components
1. cultural desire 2. cultural awareness 3. cultural knowledge 4. cultural skills 5. cultural encounters
what are 4 common mental health problems
1. depression 2. anxiety 3. substance abuse 4. violence
a 62 year old pt tells the nurse that he is in excellent health and does not take any medications. what is the most appropriate response by the nurse to follow up on the pts statement? 1. do you avoid taking drugs because of bad experiences 2. which medications have you taken in the past 3. that is hard to believe. most men your age take medications 4. do you use over the counter medications or herbal preparations
1. do you avoid taking drugs because of bad experiences
a nurse is assessing a woman whose religious beliefs do not allow blood transfusions. she has severe anemia, is very weak, and has altered mental status. what should the nurse do to provide culturally competent care to this woman? 1. examine his or her feelings about the role of religious beliefs in making decisions about life 2. recognize that he or she cannot provide care to patients whose religious beliefs endanger their lives 3. try to convince the patient to have a blood transfusion to save her own life 4. determine whether the patient is competent to make her own decisions about health care
1. examine his or her feelings about the role of religious beliefs in making decisions about life
what senses do we assess
1. eyes 2. ears 3. nose 4. mouth 5. touch
what are the 16 things you are supposed to cover in a pts physical examination
1. general survey 2. skin hair and nails 3. head 4. eyes 5. ears 6. nose 7. mouth 8. neck 9. chest and lungs 10. breasts 11. heart 12. peripheral vascular 13. abdomen 14. musculoskeletal 15. neurologic 16. gynecologic
what are 5 common neurological problems
1. headache 2. dizziness 3. seizures 4. loss of consciousness 5. confusion
what special communication considerations should you keep in mind
1. hearing impaired 2. visually impaired 2. physically impaired
steps of cardiac assessment
1. inspect- symmetry, color, warmth 2. palpate- apical pulse- look for lumps 3. auscultate @ erbs point
what are the techniques of physical assessment
1. inspection 2. palpation 3. percussion 4. ausculation
the role of critical thinking in nursing practice includes
1. interpretation 2. analysis 3. evaluation 4. explanation 5. self-regulation 6. clinical decision making
what are the 3 phases of the interview
1. introduction phase 2. discussion phase 3. summary phase
what are the 4 types of sensory perception assessments
1. neurological 2. mental health 3. senses 4. neuromuscular
the nurse-patient helping relationship consists of 3 phases. what are they
1. orientation 2. working 3. termination
in a neurological assessment, you want to ask the patient four things
1. person: "tell me your name" 2. place: "tell me where you are" 3. time: "tell me what year you're in, what day it is" 4. situation: "tell me why you are here" if the pt can answer all things correctly, it's charted as "alert x4"
A 3-year-old boy in respiratory distress is treated in the emergency department. A diagnosis of acute spasmodic laryngitis (spasmodic croup) is made. At the time of discharge, the mother asks how to handle another attack at home. What should the nurse recommend? 1 Placing him near a cool-mist humidifier 2 Bringing him to the emergency department 3 Giving him an over-the-counter cough syrup 4 Offering him warm tea sweetened with honey
1. placing him near a cool mist humidifier
what are 4 types of intrapersonal communication
1. positive self talk 2. negative self talk 3. meditation 4. prayer
within a pts general health history, what are the four things you should consider
1. present health status 2. past health history 3. family history 4. personal/psychosocial history
what are the signs of pregnancy
1. presumptive symptoms (symptoms experienced by the woman) 2. probable signs (changes observed by the nurse) 3. positive signs (findings that prove the presence of a fetus)
newborn BP
60-90/20-60
auscultation of lung sounds posteriorly-- one should assess how many locations??
10 locations
BUN range
10-20 mg/dL
normal PT time
11-12.5 sec
Adult Blood Pressure
110-120/60-79
adult BP
110-120/60-79
which age group has the following fine motor skills: may hold cup and spoon and feed self fairly well with practice, can offer toys and release them, releases cube in cup
12 month old
which age group has the following gross motor skills: able to twist and turn and maintain posture, able to sit from standing position, may stand alone - at least momentarily
12 month old
Adolescent Respiratory Rate
12-16
adolescent RR
12-16
normal Hgb for females
12-16
Toddler: Language Development
12-18 Months First words are spoken. Usually familiar ofjects or people. Simple monosyballabic words such as momma, or bye bye. 18-24 months. First sentences of two words are spoken Word errors include Under extending words. - 2 word combinations - Turn-take conversations - Gestures/simple words
adolescent
12-18 years
Adult Respiratory Rate
12-20
adult RR
12-20
Newborn/Infant Heart Rate
120-160
newborn HR
120-160
how many bones does the face have
14 - they protect facial structures
Hgb for males
14-18 g/dL
which age group has the following fine motor skills: can put raisins into bottle, take off shoes and pulls toys, builds tower of 2 cubes, scribbles, uses cup well but rotates spoon
15 month old
which age group has the following gross motor skills: walks alone well, able to seat self in chair, creeps upstairs, cannot throw ball without falling
15 month old
normal platelet count
150,000-400,000/mm3
which age group has the following fine motor skills: builds tower of 3-4 cubes, turns pages in book 2-3 at a time, manages spoon without rotating
18 month old
which age group has the following gross motor skills: may walk up and down stairs holding hand, may show running ability
18 month old
School-Age Respiratory Rate
18-30
school age child RR
18-30
Nagele's Rule
1st day of last period + 7 days - 3 months
A 2-month-old infant is being treated with sequential casts for bilateral clubfoot (talipes equinovarus). New casts have just been applied. What should the nurse evaluate to determine that circulation to the feet remains sufficient? 1. alignment of legs on x-ray 2. warmth of the toes of both feet 3. mobility of the knees when flexed 4. presence of posterior tibial pulses
2
A Foley catheter was placed with an urimeter for a client with heart failure receiving furosemide. The output is 45 mL/hour, cloudy, and has sediment. How should the nurse interpret these findings? 1. the furosemide is causing dehydration 2. cloudy urine may be indicative of infection 3. the client has inadequate urine output 4. all of the indications are within normal findings
2
A client with a diagnosis of anemia is receiving packed red blood cells. What is the most important action by the nurse when administering the transfusion? 1. warning the client about the possibility of fluid overload 2. monitoring the clients response, particularly within the first 10 minutes 3. adjusting the clients transfusion flow rate so that it infuses a consistent rate during the procedure 4. having the client tested for human immunodeficiency virus (HIV) before administering the blood transfusion
2
A client's monitor shows a PQRST wave for each beat and indicates a rate of 120 beats/minute. The rhythm is regular. What does the nurse conclude that the client is experiencing? 1. atrial fibrillation 2. sinus tachycardia 3. ventricular fibrillation 4. first-degree ventricular block
2
A nurse administers a parenteral preparation of potassium slowly and cautiously to avoid which complication? 1. acidosis 2. cardiac arrest 3. psychotic like reactions 4. edema of the extremities
2
A nurse is auscultating the lungs of a healthy female patient and hears crackles on inspiration. What action can the nurse take to ensure this is an accurate finding? 1. Make sure the bell of the stethoscope is used rather than the diaphragm. 2. Ask the patient to cough then repeat the auscultation. 3. Ask the patient not to talk while the nurse is listening to the lungs. 4. Change the patient's position to ensure accurate sounds.
2
A nurse suspects a viral infection or upper respiratory allergies when the patient describes the sputum as being which color? 1. White 2. Clear 3. Yellow 4. Pink tinged
2
A patient complains of pain in the calf when walking. Which question should the nurse ask for further data? 1. "Does your calf also swell when this pain occurs?" 2. "Does the pain go away when you stop walking?" 3. "Do you become short of breath when you're walking?" 4. "Do you feel dizzy when the pain occurs?"
2
In assessing the mood of older adult patients, a nurse documents which finding as abnormal? 1. Sadness and grief after returning from the funeral of a long-time friend 2. Depression that interferes with the ability to perform activities of daily living 3. Frustration about rearranging the day's schedule to attend a grandson's birthday party 4. Crying about the unexpected death of a pet that had been with the family 12 years
2
On inspection of the eye of an 82-year-old woman, the nurse notes which finding as normal? 1. Opaque coloring of the lens 2. Clear cornea with a gray-white ring around the limbus 3. Dilated pupils when looking at an item in her hand 4. Impaired perception of the colors yellow and red
2
The nurse applies fetal and uterine monitors to the abdomen of a client in active labor. When the client has contractions, the nurse notes a 15 beats/min deceleration of the fetal heart rate below the baseline lasting 15 seconds. What is the next nursing action? 1. calling the primary healthcare provider 2. changing the maternal position 3. obtaining the maternal blood pressure 4. preparing the environment for an immediate birth
2
The nurse instructs a pregnant woman in labor that she must avoid lying on her back. The nurse bases this instruction on the information that the supine position is primarily avoided because it can do what? 1. prolong the course of labor 2. cause decreased placental perfusion 3. lead to transient episodes of hypertension 4. interfere with free movement of the coccyx
2
When a patient complains of chest pain, which question is pertinent to ask to gain additional data? 1. "What were you doing when the pain first occurred?" 2. "What does the pain feel like?" 3. "Do you have episodes of shortness of breath?" 4. "Has anyone in your family ever had a similar pain?"
2
Where does a nurse palpate to assess the posterior tibial pulse? 1. Behind the knee in the popliteal fossa 2. The inner aspect of the ankle below and slightly behind the medial malleolus 3. Over the dorsum of the foot between the extension tendons of the first and second toes 4. The outer side of the ankle below and slightly behind the lateral malleolus
2
Which finding of a preschooler during a cardiovascular system examination is abnormal? 1. Heart rate of 106 beats/min 2. Failure to gain weight because of fatigue while eating 3. Continuous low-pitched vibration heard over the jugular vein 4. Pulse increasing on inspiration and decreasing on expiration
2
interpersonal communication is
2 or more people communicating, either formal or informal
A 50-year-old patient asks how he can reduce his risk of colon cancer. What is the most appropriate response by the nurse? 1. "A diet high in animal protein reduces the risk." 2. "Regular exercise to reduce body fat helps prevent colon cancer." 3. "Taking antacids for heartburn can help prevent colon cancer." 4. "Taking vitamin C daily helps reduce the risk."
2.
A man weighs 265 pounds and is 6 feet 4 inches tall. Based on these data, how does the nurse classify his weight? 1. Overweight 2. Class I obesity 3. Class II obesity 4. Class III obesity
2.
A pathology report states that a client's urinary calculus is composed of uric acid. Which food item should the nurse instruct the client to avoid? 1 Milk 2 Liver 3 Cheese 4 Vegetables
2.
A patient states that he has experienced "a lot" of unintentional weight loss over the past 4 months. The nurse measures his height and weight (5 feet 11 inches, 170 pounds) and determines that his body mass index is 22.7. Which of the following is the most appropriate action to better evaluate his recent weight loss? 1. Calculate his desirable body weight. 2. Ask, "What is your usual body weight?" 3. Record what he ate in the last 24 hours. 4. Determine his hip-to-waist ratio.
2.
A patient with a missed menstrual period and nausea has which signs and symptoms of pregnancy? 1. Questionable 2. Presumptive 3. Probable 4. Positive
2.
The nurse notes that a 2-year-old child has a cough that sounds like a bark. What other findings should the nurse anticipate? Wheezing and coarse rhonchi bilaterally Labored breathing and fever Hyperresonance with percussion Productive, blood-tinged sputum
2.
When assessing a patient's abdomen, the nurse uses assessment techniques in which order? 1. Inspection, palpation, and auscultation 2. Inspection, auscultation, and palpation 3. Auscultation, inspection, and palpation 4. Palpation, auscultation, and inspection
2.
Which instruction should the nurse provide the client who is concerned about contracting amebic dysentery during foreign travel? 1 Apply insect repellent. 2 Drink only bottled water. 3 Avoid drinking pasteurized milk. 4 Obtain vaccine prior to foreign travel.
2.
The nurse is interviewing an adult Navajo woman. Which statement demonstrates cultural sensitivity and acceptance of the patient? 1. "How often do you visit the medicine man for your health care?" 2. "Tell me about your health care practices and beliefs" 3. "Many Navajo people are afraid of hospitals. Are you afraid?" 4. "Have you ever had a physical examination with a physician or a nurse practitioner?"
2. Tell me about your health care beliefs and practices
the nurse is caring a patient with a femur fracture. an immobilization device is used to maintain the alignment of the femur. the nurse palpates the top of the foot to make which determination? 1. amount of drainage from wound 2. adequacy of blood perfusion to the foot 3. presence of air in the underlying tissue 4. range of motion to the foot
2. adequacy of blood perfusion to the foot
a school nurse notices a boy with a bandage on his arm and black fluid under the edge of the bandage. she asked the teen what happened to his arm. he replies that his mother applied axle grease to a boil. what is the nurses most appropriate response to this boy? 1. tell the teen to remove the bandage and wash his arm 2. ask the teen what the boil looks like and feels like and if the axle grease is healing the boil 3. advise the teen to tell his mother to use antibiotic cream rather than axle grease 4. suggest that the teen see a health care provider because the axle grease will infect the boil
2. ask the teen what the boil looks like and feels like and if the axle grease is healing the boil
A client is admitted for dehydration, and an intravenous (IV) infusion of normal saline is started at 125 mL/hour. One hour later, the client begins screaming, "I can't breathe!" How should the nurse respond? 1 Discontinue the IV and notify the healthcare provider. 2 Elevate the head of the client's bed and obtain vital signs. 3 Assess the client for allergies and change the IV to an intermittent lock. 4 Contact the healthcare provider to request a prescription for a sedative
2. elevate the head of the clients bed and obtain vital signs
A nurse is caring for a client experiencing an acute episode of bronchial asthma. What should nursing interventions achieve? 1 Curing the condition permanently 2 Raising mucous secretions from the chest 3 Limiting pulmonary secretions by decreasing fluid intake 4 Convincing the client that the condition is emotionally based
2. raising mucous secretions from the chest
which age group has the following fine motor skills: able to turn doorknob, able to take off shoes and socks, able to build 7-8 block tower, dumps raisins from bottle following demonstration
24 month old (2 years)
which age group has the following gross motor skills: may walk up stairs by self, step 2 ft each step, able to walk backward, able to kick ball
24 month old (2 years)
Toddler Respiratory Rate
24-40
toddler RR
24-40
prenatal visits are recommended every 4 weeks up to _____
28 weeks
prenatal visits are recommended every 2 weeks from _____
28-36 weeks
3. Which patient has the greatest risk for hypertension? 1. An Asian man who is 5 ft 5 in (165 cm) tall, weighs 125 lbs (56.7 kg), and complains of a headache over his forehead and eyes 2. A Cheyenne Indian woman who complains of a gnawing, burning epigastric pain radiating to her neck and jaw 3. An African American man who has type 2 diabetes mellitus, exercises once a month, and drinks two-to-three alcoholic drinks a night with dinner 4. A Caucasian woman who has a family history of heart disease and complains of pain in her chest when she takes a deep breath
3
A client with a coronary occlusion is experiencing chest pain and distress. Why does the nurse administer oxygen? 1. to prevent dyspnea 2. to prevent cyanosis 3. to increase oxygen concentration to heart cells 4. to increase oxygen tension in the circulating blood
3
A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and a PCO 2 of 60 mm Hg. What complication does the nurse conclude the client is experiencing? 1. metabolic acidosis 2. metabolic alkalosis 3. respiratory acidosis 4. respiratory alkalosis
3
A nurse finds the patient's anteroposterior diameter of the chest to be the same as the lateral diameter. Based on this finding, what additional data would the nurse anticipate? 1. Bronchial breath sounds in the posterior thorax 2. Decrease in respiratory rate 3. Decreased breath sounds on auscultation
3
A patient has an infection of the terminal bronchioles and alveoli that involves the right lower lobe of the lung. Which abnormal findings are expected? 1. Dyspnea with diminished breath sounds bilaterally 2. Asymmetric chest expansion on the right side 3. Fever and tachypnea with crackles over the right lower lobe 4. Prolonged expiration with an occasional wheeze in the right lower lobe
3
An adolescent tells a nurse that, while he was riding in a friend's car, the friend was stopped by the police for driving while intoxicated. Which assessment tool would be most appropriate to use with this adolescent? 1. Faces Pain Scale 2. Pediatric Symptom Checklist (PSC) 3. Guidelines for Adolescent Prevention (GAP) 4. Oucher Scales
3
young-old
65-74
Each year, a client takes many trips to other countries. The client reports leg swelling during the long flights. How should the nurse best advise this client when traveling? 1. relax in a reclining position 2. sit upright with legs extended 3. walk around at least every hour 4. sit in any position that relieves pressure on the legs
3
How does a nurse determine jugular vein pulsations? 1. Elevates the head of the bed about 90 degrees and looks for the jugular vein pulsation parallel to the sternocleidomastoid muscle as the head of the bed is slowly lowered 2. Looks for jugular vein pulsations at the jaw line as the patient turns from supine to a side-lying position 3. Elevates the head of the bed until the external jugular vein pulsation is seen above the clavicle 4. Positions the patient supine and asks him or her to cough; looks for jugular vein pulsations during the cough
3
On auscultation of the heart, the nurse recognizes which expected finding? 1. A low-pitched blowing sound is heard over the abdominal aorta. 2. A high-pitched vibration is heard over the base of the heart. 3. The S1 heart sound is louder at the apex of the heart. 4. The S3 heart sound sounds like "Ken-tuck-y."
3
Sublingual nitroglycerin tablets are prescribed to control periodic episodes of chest pain in the patient with stable angina. Which instruction should the nurse include when teaching the client about sublingual nitroglycerin? 1. once the tablet is dissolved, spit out the saliva 2. take tablets 3 minutes apart up to a maximum of five tablets 3. common side effects include headache and low blood pressure 4. once opened, the tablets should be refrigerated to prevent deterioration
3
Which finding is an expected age-related change for a woman 80 years old? 1. Kyphosis 2. Back pain 3. Loss of height 4. Depression
3
Which patient has the greatest risk for hypertension? 1. An Asian man who is 5 ft 5 in (165 cm) tall, weighs 125 lbs (56.7 kg), and complains of a headache over his forehead and eyes 2. A Cheyenne Indian woman who complains of a gnawing, burning epigastric pain radiating to her neck and jaw 3. An African American man who has type 2 diabetes mellitus, exercises once a month, and drinks two-to-three alcoholic drinks a night with dinner 4. A Caucasian woman who has a family history of heart disease and complains of pain in her chest when she takes a deep breath
3
Which question gives the nurse further information about the patient's complaint of chest pain? 1. "Have you had your influenza immunization this year?" 2. "Are there environmental conditions that may affect your breathing at home?" 3. "How would you describe the chest pain?" 4. "Has the chest pain been interrupting your sleep?"
3
While examining the ear of an infant with an otoscope, the nurse pulls down on the ear for which reason? 1. Increases the depth that the otoscope can be inserted 2. Stabilizes the ear to avoid injury if the infant moves the head suddenly 3. Enhances visualization of the tympanic membrane by straightening the ear canal 4. Facilitates drainage of cerumen from the ear canal, allowing better visualization of inner ear structures
3
While inspecting the legs of a male patient, the nurse notes that the skin is shiny and taut with little hair growth. Which additional data would the nurse find to indicate that this patient has peripheral arterial disease? 1. Pitting edema of one or both feet or legs 2. Increased circumference in the thighs bilaterally 3. Pale, cool legs with diminished-to-absent dorsalis pulses 4. Pain when legs are dependent that is relieved when legs are elevated
3
newborns are nose breathers until what age?
3 months
preschool
3-5 years
A 9-year-old child with chronic kidney disease is undergoing peritoneal dialysis. For which associated complication should the nurse monitor the child? 1 Petechiae 2 Abdominal bruit 3 Cloudy return dialysate 4 Increased blood glucose level
3.
A nurse performing an abdominal examination on a 37-year-old woman would document which finding as abnormal? 1. No aortic pulsations to light or deep palpation 2. Bowel sounds every 15 seconds in the lower quadrants 3. Bulges observed when coughing 4. Silver-white striae and a faint vascular network
3.
A patient reports a gnawing, burning pain in the midepigastric area that is aggravated by bending over or lying down. Which additional question does the nurse ask for the symptom analysis? 1. "Do you have a family history of this type of pain?" 2. "How long ago did you eat?" 3. "Do you have any symptoms such as nausea with this pain?" 4. "Have you noticed any yellow coloring in your eyes or on your skin?"
3.
A patient reports having abdominal distention and having vomited several times yesterday and today. What question is appropriate for the nurse to ask in response to this information? 1. "Has there been a change in the amount of the distention?" 2. "Did you have heartburn before the vomiting?" 3. "What did the vomitus look like?" 4. "Have you noticed a change in the color of your urine or stools?"
3.
The nurse auscultates the abdomen to gain information regarding: 1. the metabolic activity of the liver. 2. the production of erythrocytes by the spleen. 3. the peristaltic activity of the intestinal tract. 4. the perfusion of the mesentery.
3.
The nurse includes questions about chest pain as part of an abdominal history because myocardial pain can be: a. associated with ulcer disease. b. caused by esophageal herniation or rupture. c. perceived as esophageal and stomach pain. d. related to congenital abdominal defects.
3.
The nurse is preparing to perform an abdominal assessment. In which position should the patient be placed for abdominal assessment? 1. Sitting upright on the examination table 2. In a high-Fowler's position 3. Supine 4. In a left lateral position
3.
The nurse suspects a foreign body in a young child's nose. Which finding is most likely to cause the nurse to suspect this? The mother states that the child plays with toys. There is purulent discharge coming from the child's nose. There is a foul-smelling odor coming from the child's nose. The child cries when lying down.
3.
The nurse suspects that a child has sensory impairment. At what age can the child undergo sensory neurologic testing? At least 6 months old Toddlers Kindergarten age Middle school age
3.
list the bones of the spine
7 cervical 12 thoracic 5 lumbar 5 sacral
Which is an expected finding of an abdominal examination of an adult? 1. Abdomen has a rounded contour 2. Venus hum over the epigastrium 3. High-pitched gurgles every 5 to 15 seconds 4. Swishing sounds over the abdominal aorta
3.
Why does the nurse ask a patient which medications he takes as part of a nutritional assessment? 1. Medications must be taken with food to avoid irritation to the gastrointestinal system. 2. Many drugs affect nutritional intake requirements; thus adjustments to the diet must be made. 3. The absorption and bioavailability of some medications are affected by food. 4. Some medications taste bad and may interfere with the appetite.
3.
an older man who is near death has been admitted to the hospital, and his family members are at his bedside. which question or statement should the nurse use during the admission assessment to address the spiritual needs of the patient and his family appropriately? 1. "what is your religion? ill make the appropriate spiritual arrangements" 2. tell me what death means to people from your culture 3. are there any special needs that you and your family request at this time 4. ill call the hospital priest so he can administer last rites
3. are there any special needs that you and your family request at this time
The healthcare provider prescribes theophylline to be given intravenously for the client experiencing an acute asthma attack. What does the nurse teach the client is the function of this medication? 1 Antibiotic 2 Antihistamine 3 Bronchodilator 4 Expectorant
3. bronchodilator
which assessment data are determined by the use of a goniometer? 1. auscultation of fetal heart tones 2. inspection of the cervix 3. measurement of joint flexion 4. assessment of hearing
3. measurement of joint flexion
a nurse is caring for a woman who has just been pronounced dead. which statement by the nurse indicates culturally competent care? 1. which funeral home would you like notified of your mothers death? 2. we will be moving her to the morgue in about 30 minutes 3. would you like some time alone with your mother for any specific ceremonies 4. here are some of her personal belongings that were in drawer
3. would you like some time alone with your mother for any specific ceremonies
What is the normal value of inspiratory reserve volume?
3.0 L
Albumin range
3.5-5
which age group has the following fine motor skills: able to build 8 block tower, scribbling techniques continue, feeds self with increased neatness, dumps raisins from bottle spontaneously
30 month old (2 1/2 years)
which age group has the following gross motor skills: able to jump from object, walking becomes more stable; wide-based gait decreases, throws ball overhanded
30 month old (2 1/2 years)
PTT (partial thromboplastin time)
30-40 sec
Newborn/Infant Respiratory Rate
30-60
newborn RR
30-60
respiratory rate of newborns is
30-60 breaths/min
normal amount of urine output per hour
30-60ml/hr
triglycerides for females
35-135
when does hormonal function start to decrease for women
35-40
prenatal visits are recommended weekly after ____
36 weeks
Hct for females
37-47
A client with impaired peripheral pulses and signs of chronic hypoxia in a lower extremity is scheduled for a femoral angiogram. What would be appropriate for the nurse to include in the postprocedure plan of care? 1. elevate the foot of the bed 2. perform urinary catheter care every 12 hours 3. place in the high-fowler position 4. perform a neurovascular assessment every 2 hours
4
A nurse is developing a teaching plan for a client with lower extremity arterial disease (LEAD). Which information will the nurse include in the teaching plan? 1. trimming toenails so that they are short and rounded 2. checking bathwater temperature by putting the toes in first 3. using alcohol to rub hands, feet, legs, and arms at least two times a day 4. seeking professional treatment for any injuries to the extremities
4
what is the formula for BMI
705 * weights(lbs)/height(in)^2
Glucose range
74-106
After several episodes of intermittent abdominal pain and vomiting, a 5-month-old infant is admitted to the pediatric unit. A diagnosis of intussusception is made. What is the priority nursing assessment that will help confirm the diagnosis? 1 Auscultating for bowel sounds 2 Listening for high-pitched crying 3 Measuring fluid intake and output 4 Observing characteristics of stools
4
During an initial prenatal visit the nurse identifies which factor as consistent with a high-risk pregnancy? 1. Patient is 18 years old. 2. Patient height is 5 feet 4 inches. 3. Birth weight of infant with last pregnancy was 2800 g. 4. Patient smokes one-half pack of cigarettes a day.
4
During inspection of the respiratory system the nurse documents which finding as abnormal? 1. Skin color consistent with patient's ethnicity 2. 1:2 ratio of anteroposterior to lateral diameter 3. Respiratory rate is 20 breaths per minute 4. Patient leaning forward with arms braced on the knees
4
How does the nurse palpate the chest for tenderness, bulges, and symmetry? 1. Uses the fist of the dominant hand to gently tap the anterior, lateral, and posterior chest, comparing one side with another 2. Uses the ulnar surface of one hand to palpate the anterior, posterior, and lateral chest, comparing one side with another 3. With the tips of the fingers, palpates the skin over the chest and the alignment of vertebrae 4. With the palmar surface of fingers of both hands, feels the consistency of the skin over the chest and the alignment of vertebrae
4
On assessment of the neurologic status of a 4-month-old infant, the nurse notes which finding as abnormal? 1. The infant abducts and extends arms and legs when startled. 2. When the infant's sole is touched, the toes flex tightly in an attempt to grasp. 3. When stroking the infant's foot from sole to great toes, there is fanning of the toes. 4. The infant steps in place when held upright with feet on a flat surface.
4
The nurse instructs the client admitted for an acute exacerbation of chronic obstructive pulmonary disease (COPD) about the importance of assessing for right-sided heart failure after discharge. What does the nurse instruct the client to assess for? 1. increased appetite 2. clubbing of the nail beds 3. hypertension 4. weight gain
4
The nurse is listening to the patient's heart at the left sternal border (LSB) at the second intraclavicular space (ICS). Which area is being auscultated? 1. Erb's point 2. Mitral area 3. Aortic area 4. Pulmonic area
4
The nurse notes which finding as abnormal during a thoracic assessment of an older adult? 1. A skeletal deformity affecting curvature of the spine 2. Shortness of breath on exertion 3. An increase in anteroposterior diameter 4. Bronchovesicular breath sounds in the peripheral lung fields
4
What is an expected finding of the newborn's vision that the nurse teaches the parents? 1. Small tears will be noted when their newborn cries. 2. Peripheral sight does not develop until age 3 or 4 months. 3. The newborn can only distinguish the colors of blue and green. 4. The newborn is nearsighted and cannot see items unless they are close.
4
What is the most accurate technique for detecting a venous thrombosis at the bedside? 1. Dorsiflex the calf and note if the patient complains of pain. 2. Elevate one leg above the level of the heart to determine if the veins empty. 244 3. Palpate the pulses distal to the areas of the suspected thrombosis. 4. Measure the thigh circumference to detect an increase from the baseline.
4
What question does a nurse ask a patient with a history of pancreatitis who is complaining of abdominal pain? 1. "Which foods aggravate the pain?" 2. "Have you recently traveled outside the United States?" 3. "Have you noticed a change in your bowel habits?" 4. "How severe is the pain on a scale of 0 to 10?"
4
When developing a plan of care for a client who had a cardiac catheterization via a femoral insertion site, what should the nurse include? 1. ambulating the client 2 hours after the procedure 2. checking the vital signs every 15 minutes for 8 hours 3. keeping the client nothing by mouth for 4 hours after the procedure 4. maintaining the supine position for a minimum of 4 hours
4
When examining the genitalia of a 3-year-old boy, which position is ideal? 1. Prone position with legs flexed in a frog leg position 2. Supine position with knees spread and ankles spread apart 3. Lithotomy position with knees and ankles spread apart 4. Sitting position with knees spread and ankles crossed
4
Which are expected findings of a newborn's respiratory assessment? 1. Thoracic breathing 2. A 1:2 ratio of anteroposterior-to-lateral diameter 3. Flaring of the nares noted on inspiration 4. Bronchovesicular breath sounds in the peripheral lung fields
4
Which risk is associated with estrogen therapy in a client who smokes? 1. hypcalcemia 2. vaginal bleeding 3. multiple pregnancies 4. thromboembolic disorders
4
the internal structures of the female reproductive system is supported by _____ pairs of ligaments
4
which age group has the following fine motor skills: grasps rattle, plays with hands together, inspect hands, carries object to mouth
4 month old
which age group has the following gross motor skills: actively lifts head up and looks around, rolls from prone to supine, no head lag when pulled to sitting position, when pulled into sitting position, shows only slight head lag
4 month old
An older woman is 5 feet 2 inches tall and weighs 100 pounds. To best understand her dietary intake, which question is most appropriate? 1. "Who prepares your meals on a daily basis?" 2. "What are your favorite foods?" 3. "How do you get to the grocery store each week?" 4. "Could you describe what you eat on a typical day?"
4.
The mother of a child tells the nurse that she is concerned that her child may be having trouble hearing. Which statement made by a parent suggests a possible hearing impairment in the child? "My 5-month-old baby is babbling but not saying any words." "My 3-year-old son does not listen to me." "I have a hard time understanding my 15-month-old baby." "My 4-month-old baby does not respond to loud noise."
4.
The nurse is assessing a patient's abdomen and suspects ascites. Which technique is used to confirm the presence of abdominal ascites? a. Auscultation of fluid movement within the abdominal cavity b. Palpation of rebound tenderness c. Palpation of pitting edema of the abdomen d. Percussion of dullness over dependent areas of the abdomen
4.
What is the nurse assessing when measuring from the patient's symphysis pubis to the top of the fundus? 1. Fetal development 2. Fetal lie and position 3. Attitude of the fetus 4. Gestational age
4.
Which drug prescribed to a client with a urinary tract infection (UTI) turns urine reddish-orange in color? 1. Amoxicillin 2 Ciprofloxacin 3 Nitrofurantoin 4 Phenazopyridine
4.
Which technique does the nurse use to palpate a patient's abdomen? 1. Asks the patient to breath slowly though the mouth 2. Uses the heel of the hand to perform deep palpation 3. Uses the left hand to lift the rib cage away from the abdominal organs 4. Depresses the abdomen 1 cm for light palpation
4.
A client had surgery for a ruptured appendix. Postoperatively, the health care provider prescribes an antibiotic to be administered intravenously twice a day. The nurse administers the prescribed antibiotic via a secondary line into the primary infusion of 0.9% sodium chloride. During the administration of the antibiotic, the client becomes restless and flushed, and begins to wheeze. What should the nurse do after stopping the antibiotic infusion? 1 Check the client's temperature. 2 Take the client's blood pressure. 3 Obtain the client's pulse oximetry. 4 Assess the client's respiratory status.
4. assess the clients respiratory status
which infection control intervention is most frequently applied? 1. wearing gloves 2. using masks 3. wearing eye protection 4. hand hygiene
4. hand hygiene
While receiving betamimetic (tocolytic) therapy for preterm labor the client begins to experience muscle tremors and exhibit signs of nervousness. She reports, "My heart is racing." The nurse identifies that the client's pulse rate is 110 beats/min and regular. What should the nurse do next? 1. discontinue the medication as per protocol 2. notify the primary healthcare provider that preterm labor has restarted 3. obtain the clients laboratory results for electrolyte levels 4. reassure the client that these are expected side effects of the medication
4. reassure the client that these are expected side effects of the medication
When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse would implement which measure to promote effective airway clearance? 1 Administer sedatives around the clock 2 Turn client every four hours 3 Increase ventilator settings as needed 4 Suction as needed
4. suction as needed
normal RBC range for females
4.2-5.4
normal RBC range for males
4.7-6.1
normal RBC range for newborns
4.8-7.1
normal RBC range for 8-12 y/o's
4.o-5.5
triglycerides for males
40-160 mg/dl
Hct for males
42-52%
murmurs normal up to _____ hours after birth
48
which age group has the following fine motor skills: can reach and pick up object, may play with toes
5 month old
which age group has the following gross motor skills: able to push up from prone and maintain weight on forearms, rolls from prone to supine, remains straight back when sitting
5 month old
the menstrual cycle has how many stages within what time frame
5 stages within a 28 day cycle
WBC for children and adults
5000-10000
what is the average age of a women going through menopause
51
how many bones are in the cranium
6
which age group has the following fine motor skills: holds spoon or rattle, drops object and reaches for 2nd offered object, holds bottle
6 month old
which age group has the following gross motor skills: begins to raise abdomen off of table, sits but still shaky posture, may sit with legs apart, holds arms straight between legs, supports almost full body weight when pulled to standing
6 month old
The nurse is performing an eye exam on a child. The nurse knows that the child will have the visual acuity of an adult at which age? 2 years 3 years 6 years 10 years
6 years
school age
6-12 years
What is the minimum heart rate of a 14 year old? Record your answer using a whole number. _____________ beats per minute
60 bpm
Adult Heart Rate
60-100
adult HR
60-100
Adolescent Heart Rate
60-90
adolescent HR
60-90
Newborn/Infant Blood Pressure
60-90/20-60
PFT (pulmonary function tests)
Assesses lungs and pulmonary reserve before anesthesia, to assess response to bronchodilator therapy and to detect pulmonary deficiencies.
older individuals are at greater risk for what in regards to mobility
falls
Albumin
A large plasma protein (found in blood) used to determine liver function.
Amniocentesis
A procedure used to detect abnormalities during pregnancy.
"WHY"
A question that can be perceived as threatening
closed-ended questions
A type of question that requires only a "Yes" or "No" response. Used to gain more precise details
Wavy motion or pulsations
ABNORMAL
Infant
AGE: 0-12 months Experience the world through senses including hearing, seeing, smelling, tasting, and touching
blanching includes..
pressing on nail bed, color should come back in less than 3 seconds
What are the 12 cranial nerves?
I - (Olfactory) 1 II - (Optic) 2 III - (Oculomotor) 3 IV - (Trochlear) 4 V - (Trigeminal) 5 VI - (Abducans) 6 VII - (Facial) 7 VIII - (Auditory or Vestibulocochlear) 8 IX - (Glossopharengeal) 9 X - (Vagus) 10 XI - (Spinal Accessory) 11 XII - ( Hypoglossal) 12
Somatic Motor
III, IV, VI, XII
A client is admitted to the hospital and benazepril is prescribed for hypertension. Which is an appropriate nursing action for clients taking this medication?
Assess for dizziness.
Mental status
Assessed by determining patient's orientation, memory, calculation ability, communication, skills, judgment, and abstraction.
Cranial Nerve VI (6)
Abducens (6 cardinal gazes, lateral movement)
CN VI
Abducens - abducts the eye
Orientation
Ability to recognize time, location, people and situation.
Cranial Nerve VIII (8)
Acoustic (hearing and equilibrium)
Toddler
Age: 1-2 Experience the world through their senses including hearing, seeing, smelling, tasting, and touching
Adolescent
Age: 12+ Able to create theories and generate many explanations for situations. They are beginning to communicate like adults
Preschool
Age: 3-5 use words that they do not fully understand, they also do not accurately understand many words used by others
School-Age
Age: 6-11 years communicate through thoughts and appreciate viewpoints of others. Words with multiple meanings and words describing things they have not experienced are not thoroughly understood
What is confidentiality?
All information regarding a patient's condition including types of tests ordered or results is confidential
CVA (cerebrovascular accident)
Also known as a stroke.
Prealbumin
Amount of protein contained in the internal organs, showing recent nutritional status.
Authoritarian
An attitude that is "paternal"
Dysphasia
Impairment of speech, not as severe as aphasia.
Expressive aphasia
Inability to communicate ideas into meaningful speech or writing.
Receptive aphasia
Inability to comprehend speech (of others and of oneself)
ATNR reflex
Birth - 6 months; examiner turns infant's head to one side when in supine position, the infant's arm and leg will extend on side face is turned to; flexion on opposite limbs May prevent rolling off
INR, PT, PTT
Blood tests used to measure coagulation and or response to anticoagulation therapy.
Ataxia
Inability to coordinate movements.
Reflection
Clarifying a phrase of sentence, or encouraging elaboration
Ca (Calcium)
Electrolyte primarily involved in bone formation, regulated by the kidneys.
Laminar blood flow is characterized by A. Parabolin velocity profile B. Murmurs C. Turbulence D. Eddy currents
D. eddy currents
K ( Potassium)
Electrolyte primarily involved in cardiac conduction/electrical activity, regulated by kidneys.
Na (Sodium)
Electrolyte primarily involved with hydration and sensory perception, regulated by kidneys.
EKG
Evaluates arrhythmias, conduction defects, myocardial injury and damage, and pericardial disease.
explain primary data
comes directly from the pt about their feelings concerns and what they have done to address their concerns
Hypoesthesia
Decreased sensation.
Aphasia
Defective or absent language function.
Residual effects
Deficits (such as weakness or spasticity) resulting from injury to CNS.
Normocephalic
Designating that the skull is symmetric and proportional to the size of the body.
Urinalysis
Detects urinary tract disease and gain basic information about kidneys and other metabolic processes.
HcG (Human Chorionic Gonadotropin)
Diagnoses pregnancy.
ABG (Arterial Blood Gas)
Diagnostic test that examines arterial blood to assess patients oxygenation status and acid-base balance.
Dysphagia
Difficulty swallowing.
tissue integrity - infant/newborn findings
Expected Findings - Skin • Preterm infants generally appear redder • Neonate may appear cyanotic in the lips, nail-beds, and feet - resolves with warming • Light skin and dark skinned newborns should have a pink tone (dark skin most easily accessed on their palms) • Newborns - skin, mucous membranes, and sclera may appear yellow Expected Findings - Hair and Nails • Scalp hair is fine and soft • Scaly crust may appear • Lanugo hair - fine hair all over the newborn's body
what is communication competence
communication that is both effective and appropriate
localized injury to the skin over a bony prominence
pressure ulcer
A client arrives in the emergency department with multiple crushing wounds of the chest, abdomen, and legs. Which are the priority nursing assessments?
Quality of respirations and presence of pulses
CT
Radiological procedure in which the use of a special scanner allows cross-sectional images of an organ to be visualized.
gravidity
total number of pregnancies
high pitched musical sounds similar to squeak, more common during expiration
wheezes
A client is admitted to the hospital with partial- and full-thickness burns of the chest and face sustained while trying to extinguish a brush fire. Which is the nurse's priority concern? 1Loss of skin integrity caused by the burns 2Potential infection as a result of the burn injury 3 Inadequate gas exchange caused by smoke inhalation 4 Decreased fluid volume because of the depth of the burns
Inadequate gas exchange caused by smoke inhalation
Rhinitis
Inflammation of the nasal mucosa.
order of abdominal assessment
Inspection Auscultation Palpation Percussion
Nystagmus
Jerky eye movements when patient tries to focus on and follow a moving object.
Active
Listening with purpose
BUN & Creatinine
Measures renal function.
A healthcare provider prescribes a diuretic for a client with hypertension. What should the nurse include in the teaching when explaining how diuretics reduce blood pressure?
Reduces the circulating blood volume
The parents of a child with spasmodic croup ask why their child is receiving humidified oxygen. What effect of humidified oxygen should the nurse include in the explanation? 1. Minimizes tissue edema 2 Provides a mode of giving inhalant drugs 3 Increases the surface tension of the respiratory tract 4 Provides an environment free of pathogenic organisms
Minimizes tissue edema
should we document while listening to a pt during the interview
NO. listen first, then document
should a pt be in a gown during the interview process
NO. the pt should remain in street clothes during the interview process and be as comfortable as possible. the pt can change into the gown after the interview, when the physical examination will begin
tissue integrity - laboratory findings
NONE
Stepping Reflex
Newborn reflex that refers to the fact that very young babies take what looks like walking steps if they are held upright with their feet just touching a flat surface; normally disappears after 2 or 3 months and reemerges later when real walking begins (typically around 1 year of age)
Primitive Reflexes
Normally disappear within 1st year of life. May reemerge following frontal lobe lesion. Include: Moro reflex, rooting reflex, suckling reflex, Palmar and plantar reflexes, Babinski reflex
Epistaxis
Nose bleed.
Hgb & Hct (Hemoglobin & Hematocrit)
Number and percentage of erythrocytes -provides oxygen to cells and body's iron stores.
what is an important tool to use in pain assessment
OLDCARTS
Trendelenburg sign
Occurs with severe subluxation of one hip When the child stands on the good leg, the pelvis looks level. When the child stands on the affected leg the pelvis drops toward the good side if there is a tilt present the child has hip dysplasia
Cranial Nerve III
Oculomotor (eye movement, pupil constriction)
CN III
Oculomotor - Most eye movement
Cranial Nerve I
Olfactory (smell)
CN I
Olfactory - Smell
CN II
Optic - Vision
Cranial Nerve II
Optic - vision
abnormal CNS signs in infant
Persistent immature signs past 4 months Frequent & persistent arching and stiffenss Leg scissoring with extension Difficulty changing diaper due to tone Lack of development of postural reactions
A client who had a myocardial infarction receives 15 mg of morphine sulfate for chest pain. Fifteen minutes after receiving the drug, the client complains of feeling dizzy. What action should the nurse take?
Place the client in the supine position and take the vital signs
what is privacy
Prevention of unauthorized intrusion, knowledge that information deemed personal or confidential won't be shared with unauthorized entities, freedom from being observed without consent
WBC
Primarily involved in fighting an infection.
Restatement
Expressing the same idea in different words to clarify and stress key points
Cranial Nerve VII (7)
Facial (smiling, taste for 2/3 of the tongue)
CN VII
Facial Nerve - facial expression/taste
Babinski's Reflex
Fanning of toes when stroking lateral edge of baby's foot. Present at birth, disappears (changes to adult response) by 24 months.
Taking a History
Primary method of collecting data on a patient's mental health.
gravidity and parity using a five-digit (gtpal) system
G - gravida T - term birth P - preterm birth A - abortions L - living children
Cranial Nerve IX (9)
Glossopharyngeal (taste, speech, gag reflex)
CN IX
Glossopharyngeal - taste/ gag reflex
newborn/infant (1-12months) HR, RR, BP
HR: 120-160 RR: 30-60 BP: 60-90//20-60
Newborn vital signs
HR: 120-160 RR: 30-60 Dramatic skin color changes with state Vision 7" Eyes move with head- monocular vision Physiologic flexion
> 18 year old HR, RR, BP
HR: 60-100 RR: 12-20 BP: 110-120//60-79
12-18 year old HR, RR, BP
HR: 60-90 RR: 12-16 BP: 94-120//62/88
6-12 year old HR, RR, BP
HR: 75-100 RR: 18-30 BP: 84-120//54-80
1-3 year old HR, RR, BP
HR: 90-140 RR: 24-40 BP: 80-112//50-80
assessment of hernia
Have patient cough, observe umbilicus for bulging
Fall risk
Primary reason for assessing balance and gait in older adults.
Cranial Nerve XII
Hypoglossal (tongue movement)
CN XII
Hypoglossal - swallowing/ speech
Protective Reactions in sitting
Progress from lateral to fwd to back protection; begins about 6 mos to 1 yr
Palmar Grasp Reflex
Reflex that occurs when a finger or small object is placed in the newborn's hand; newborn grasp the finger tight enough to be lifted from the bed; reflex disappears after 4 months can be strong enough to grip his entire weight
Tinnitus
Ringing in the ears.
what are the elements of SOAPIER
S-subjective data O-objective data A-assesment P-plan I-interventions E-evaluation R-revision
Which heart sound is normally heard in a toddler that is considered abnormal in an adult over 30-years-old?
S3
sentinel event
Safety error in which hospitals are required to report serious safety events to regulatory agencies and state health agencies
Dizziness
Sensation of light-headedness with an inability to maintain balance.
Vertigo
Sensation of movement, usually rotational motion such a spinning or whirling.
diastisis recti
Separation of the longitudinal muscles of the abdomen
Bradykinesia
Slow muscle movement.
Aura
Smell, sound, taste, visual sensation, or motor sensation that can precedena seizure.
CN XI
Spinal accessory - shoulder shrug
STNR reflex
Stimulus: Head Position, flexion or extension Response: When head is in flexion, arms are flexed, legs extended. When head in in extension, arms are extended and legs are flexed about 6 mos at times not present until 2 mos of age
Equilibrium reactions
Stimulus: displace center of gravity by tilting or moving support surface (equilibrium ball) head neck and trunk and extremities. opposite the force Response: curvature of trunk towards upward side along with extension and abduction of extremities Onset: -5-7 months: prone -7/11 months: supine -7/8 months: sitting -9-12 months: kneeling -12-21 months: standing
MRI
Superconducting magnet and radio frequency waves causing well defined image of structure.
rust sputum
TB or pneumococcal pneumonia
A nurse is teaching a client with a diagnosis of pulmonary tuberculosis about recovery after discharge. What is the most important intervention for the nurse to include in this plan? 1 Ensuring sufficient rest 2 Changing lifestyle routines 3 Breathing clean outdoor air 4 Taking medications as prescribed
Taking medications as prescribed
Romberg test
Test for balance requiring patient to stand with feet together, arms resting at sides and eyes closed. Expected finding is slight sway with ability to maintain upright posture.
Heel-toe walking
Test for balance that requires the patient to walk in a straight line, touching toes of one foot directly behind the heel of the other.
A nurse determines that the client's apical pulse rate is higher than the radial pulse and documents the pulse deficit. What does the nurse consider is the primary reason for the pulse deficit?
The client may have atrial fibrillation.
explain the percussion technique of a physical assessment
evaluates the size, borders, and consistency of internal organs
The nurse is percussing a patient's abdomen and hears tympany. Which anatomic features explain the finding of tympany with stomach percussion?
The stomach is hollow.
what is interpersonal communication
The transmission of messages between two or more people.
Medical
The type of terminology that can lead to confusion, misunderstanding, or embarassment
CBC
To detect hemorrhage, dietary deficiencies, anemia, hydration status,coagulation and infection.
Type & Crossmatch
To determine blood type before donating or receiving blood.
Blood Glucose
To directly measure glucose within the blood.
X-ray
To obtain information about bones and underlying tissue such as heart, lungs and intestines.
CN V
Trigeminal - Face sensation, mastication
Cranial Nerve V (5)
Trigeminal - chewing face & mouth touch & pain
Cranial Nerve IV (4)
Trochlear (6 cardinal gazes)
CN IV
Trochlear - moves eyes
EEG
Used to measure brain electrical activity, primarily used in detection of seizure activity.
Culture (blood, urine, sputum)
Used to test for the presence of bacteria, fungus, virus within various body fluids.
Confrontation
Used when inconsistencies are noted.
Special Motor
VII, IV, X, V, XI
Visceral Sensory
VII, IX, X
Visceral Motor
VII, IX, X, III
Somatic Sensory
VII, IX, X, V
Special Sensory
VII, IX, X, VIII, I, II
Cranial Nerve X
Vagus (senses aortic blood pressure & slows heart rate & stimulates digestive organs & taste)
CN X
Vagus nerve - gag reflex, parasympathetic innervation
A nurse has difficulty palpating the pedal pulse of a client with venous insufficiency. What action should the nurse take next?
Verify the pulse by using a Doppler.
CN VIII
Vestibulochlear - hearing & balance
Suck reflex
What reflex has a stimulus of place a nipple in the child's mouth and it touches the roof of his mouth? 3-4 mon. Helps baby eat
Which color of cerebrospinal fluid (CSF) may indicate subarachnoid hemorrhage in the client?
Yellow
Parachute Reaction
arm extension seen in 6-9 month old infants who are suddenly lowered toward an examining table from ventral suspension as if to protect themselves from falling the respones is asymmetrical in infants with hemiparesis and can be early sign of CP if legs are adducted and IR or absent
A 22-year-old white male comes to the emergency department with a concern about a mass in his testicle. In addition to his age and race, which fact is a known risk factor for testicular cancer? a. He had an undescended testicle at birth. b. His mother had breast cancer. c. He was treated for gonorrhea 18 months ago. d. He had a hydrocele during infancy.
a
A male patient tells the nurse, "I am unable to maintain an erection during sexual intercourse." Which question would the nurse ask the patient during the interview? a. do you drink alcohol frequently b. do you take phenytoin c. do you take diclofenac d. do you take any oral antihistamines
a
A nurse is palpating the lymph nodes of an 18-month-old toddler and finds enlarged postauricular and occipital nodes. What is the significance of this finding? a. This is a normal finding at this age. b. The toddler may have an ear infection. c. The toddler may have an inflammation of the scalp. d. The toddler needs to be referred to a pediatrician
a
A nurse is preparing to auscultate a patient's chest. In which area should the nurse listen to evaluate the patient's aortic valve? a. Second right intercostal space b. Third left intercostal space c. Fifth right intercostal space d. Fifth left intercostal space along the midclavicular line
a
A patient has a herpes lesion on her vulva. While examining her, the nurse should take which measures? a. Wear examination gloves while in contact with the genitalia. b. Place the patient in an isolation room. c. Wash the genitalia with alcohol or povidone-iodine (Betadine) before the examination. d. Inspect the genitalia only; reschedule the patient for a full examination after the lesion has healed
a
A patient has multiple solid, red, raised lesions on her legs and groin that she describes as "itchy insect bites." How does the nurse document these lesions? a. Wheals b. Bullae c. Tumors d. Plaques
a
A patient is prescribed long-term therapy of an antihistamine drug for allergies. Which possible side effect should the nurse inform the patient? a. vaginal dryness b. orgasmic disorder c. erectile dysfunction d. ejaculatory dysfunction
a
A patient with darkly pigmented skin has been admitted to the hospital with hepatitis. What is the best way for the nurse to assess for jaundice in this patient? a. Inspect the color of the sclera. b. Inspect genitalia for color. c. Blanch the fingernails. d. Jaundice cannot be assessed in patients with darkly pigmented skin.
a
During an assessment, the nurse finds that a pregnant patient consumes alcohol. Which nursing intervention is the most effective approach for dealing with values conflict? a. use a matter-of-fact, real approach with the patient b. ignore an unrealistic display of optimism from the patient c. use direct, challenging statements regarding substance abuse d. do not provide up-front information the patient
a
During inspection of the mouth of a 72-year-old male patient, the nurse notices a red lesion at the base of his tongue. What additional information does the nurse obtain from this patient? a. Alcohol and tobacco use b. Date of his last dental examination c. How well his dentures fit d. history of gum disease
a
The nurse believes a male patient has a sexually transmitted disease. Which symptom is commonly associated with STDs? a. Penile discharge b. Difficulty maintaining an erection c. Difficulty initiating a urine stream d. A heavy feeling in the scrotum
a
The nurse is assessing a patient using a goniometer. What is this instrument used for? a. Range of motion b. Muscle strength c. Joint symmetry d. Length of extremity
a
The nurse is assessing a patient's muscle strength of the trapezius muscle. The nurse will apply resisting force while the patient: a. shrugs her shoulders. b. moves her jaw laterally. c. flexes her elbow. d. extends her knee.
a
The nurse is caring for a bedridden patient. During the physical examination, the nurse observes that the patient has intact, nonblistered skin with nonblanchable erythema at the sacral area. Which stage of pressure injury does the nurse suspect in the patient? a. I b. II c. III d. IV
a
The nurse is caring for a patient with loss of voluntary motor function following a head injury. Which area of the cerebrum is likely to be affected? a. the frontal lobes b. the parietal lobes c. the occipital lobes d. the temporal lobes
a
The nurse is caring for a pregnant patient with diabetes mellitus. Which intervention performed by the nurse may increase the risk of skin breakdown in the patient? a. providing warm water for the patient to soak the feet b. inspecting both of the feet for redness or dry areas c. not using pediculicidal shampoos on the patient d. giving the patient a back massage using effleurage
a
The nurse is explaining the prostate exam to a male patient. The nurse explains that the __ surface is palpated during the examination. a. anterior rectal surface b. anorectal junction c. anterior prostate surface d. deep external sphincter surface
a
The nurse is performing a skin assessment and finds that the patient has milia. In which age group would this be an expected finding? a. Newborns b. Young children c. Adolescents d. Older adults
a
The nurse is reading a report from the patient's chart and sees a note stating the prostate is hard and irregular. The nurse suspects: a. prostate cancer. b. benign prostate hypertrophy (BPH). c. prostatitis. d. rectal cancer.
a
The nurse is teaching a parent about risk factors associated with the skin for their school-age child. What would the nurse include as the most common cause of skin lesions for this age group? a. Communicable disease and bacterial infection b. Changes in skin turgor and skin tone c. Maturation of melanocytes, causing changes in skin color d. Skin inflammation from sebaceous gland activity
a
The nurse uses the PLISSIT model while working with a couple experiencing sexual health problems. Which action would the nurse take first? a. ask the couple permission to begin a discussion on sexuality b. refer the couple to make an appointment with a sex therapist c. recommend methods to improve the couple's sexual health d. inform the couple about all of the available treatment options
a
The primary health care provider instructs the nurse to apply a bandage on a patient's injured leg. The nurse finds that the patient is anxious. Which nursing action would be taken first in this situation? a. explain the procedure to the patient b. notify the primary health care provider c. apply the bandage to the patient immediately d. elevate the patient's leg for 15 minutes before applying the bandage
a
What does the nurse assess for during each prenatal visit? a. Blood pressure b. Hemorrhoids c. Personal habits (smoking, alcohol consumption) d. Visual acuity
a
What would be an abnormal finding for a 7-year-old African American boy? a. Abdominal distention b. Umbilical hernia c. Abdominal breathing d. Tenseness of abdominal muscles
a
Which assessment finding does the nurse expect to observe in a child with cerebral palsy? a. spasticity b. paraplegia c. quadriplegia d. osteoarthritis
a
Which assessment finding would be most important to document in a patient with known liver disease who has a distended, taut abdomen? a. Abdominal girth b. Dentition condition c. Benign cardiac murmurs d. Daily ambulatory distance
a
Which device is most appropriate for preventing foot drop in a patient on bed rest? a. splint b. trapeze bar c. transfer belt d. antiembolism hose
a
Which device is most helpful for repositioning and transferring patients with functional upper body strength? a. trapeze bar b. mechanical lift c. transfer board d. lateral assist device
a
Which finding is considered abnormal during late pregnancy? a. Watery vaginal discharge b. Hemorrhoids c. Lordosis d. Abdominal striae
a
Which finding is expected during a rectal exam? a. The rectal wall is smooth. b. Severe pain is reported when the finger is introduced through the anus. c. Hard stool is present in the rectum. d. The anus is surrounded by white flat lesions
a
Which finding on a 2-month-old baby is considered abnormal and requires further follow-up? a. The anterior fontanelle is not palpable. b. The thyroid gland cannot be palpated. c. The head circumference is slightly greater than the chest circumference. d. Head lag is observed when the shoulders are lifted off the examination table
a
Which measurement is appropriate in determining the correct length of a cane for a patient? a. the floor to the hip joint b. the floor to the elbow c. the shoulder to the hip joint d. the great toe to the lesser trochanter
a
Which patient's description of pain is consistent with injury to a bone? a. "Deep, dull, and boring" b. "Cramping even when not moving" c. "Intermittent, sharp, and radiating" d. "Numbness and tingling with movement"
a
Which stage of pressure ulcer is noted to have intact skin and may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or soft), and pain? a. I b. II c. III d. IV
a
Which would be an abnormal finding during an abdominal examination of an older adult? a. Report of incontinence when sneezing or coughing b. Loss of abdominal muscle tone c. Bowel sounds every 15 seconds in all quadrants d. Silver-white striae and a very faint vascular network
a
While assessing the range of motion of the patient's knee, the nurse expects the patient to be able to perform which movements? a. Flexion, extension, and hyperextension b. Circumduction, internal rotation, and external rotation c. Adduction, abduction, and rotation d. Flexion, pronation, and supination
a
info on table: faith - abrahamic faith spiritual observance - friday night to saturday night ritual - if a male child is born, the child will be circumcised on the eighth day in a ritual called a bris Which diet does the nurse provide for a pregnant patient whose subjective assessment findings are described on the table? a. kosher diet b. pork and fish c. vegetarian d. meat and dairy products
a
the nurse is assessing a patient in the 8 month of pregnancy. the nurse would expect to find: a. the position of the heart changes slightly b. the lower legs have 3+ edema c. her blood pressure is 150/118 mm Hg d. auscultation of the heart reveals an S4 heart sound
a
which structure connects muscle to bone? a. tendon b. cartilage c. ligament d. contracture
a
what are some defense mechanisms
compensation, denial, displacement, dissociation, intellectualization, isolation, projection, rationalization, regression
In which patient would a pulsation within the epigastric area be considered a normal finding during inspection? a. A very thin patient b. An obese patient c. A patient with ascites d. An elderly patient
a very thin patient
summary
condensing and ordering data to clarify a sequence of events, helpful when a pt rambles or provides data out of order
Which nursing intervention would prevent venous stasis in a patient who has a lower limb wound? a. raising the bed height to a higher level b. elevating the patient's leg for 30 minutes c. ensuring the bandage is clean and rolled d. exposing the wound for some time before wrapping it
b
what is an diarthrodial joint
a freely moveable joint
fremitus
a palpable vibration from the spoken voice felt over the chest wall felt from palpating the back
communication is
a process of interaction between people in which symbols are used to create, exchange, and interpret messages about ideas, emotions, and mind states
value judgment
a question phrased in a way that might cause the patient to feel guilty or defensive, especially if answered in a way that conflicts with the nurses values
capillary refill should be less than ____ for newborns
a second
what is an amphiarthrodial joint
a slightly moveable joint
what is the most common eye condition in children
conjunctivitis
The nurse knows that the functions of the skin include which of the following? Select all that apply. a. Sensory input b. Protection c. Production of vitamin D d. Temperature regulation e. Production of vitamin C f. Sensory output
a, b, c, d
ethics
considers the standards of moral conduct in society
objective data can be gathered from the patient during which aspects of the physical assessment process (select all that apply) a. patient interview b. health history c. general survey d. physical examination e. laboratory testing
a, b, c, d, e
what is message
content of the communication
what is referent
event or thought initiating the communication
The nurse understands that dehiscence of a wound may occur if there is partial or total separation of the wound layers. Which patients would be at increased risk of wound dehiscence? Select all that apply. a. a malnourished patient b. an obese patient c. a young adult d. a female patient e. a patient with wound infection
a, b, e
Which teaching would the nurse include when explaining to a patient how hormonal contraceptives work? Select all that apply a. they alter the uterine environment b. they prevent ovulation c. they reduce sperm motility d. they act as a spermicidal barrier e. they thicken the cervical mucus
a, b, e
Which body mechanics principles should the nurse adopt to prevent injury at work? Select all that apply. a. bend at the knees b. pull rather than push patients or objects c. keep the spine in natural alignment while lifting or transferring d. get assistance when moving patients e. keep the weight to be lifted as close to the body as possible
a, c, d, e
The nurse is caring for an elderly patient. During the assessment the nurse finds that the patient is susceptible to developing a decubitus ulcer. Which interventions would the nurse follow to prevent decubitus ulcer in this patient? Select all that apply. a. change the patient's position once every 2 hours b. elevate the head of the bed to a 50-degree angle c. prevent the patient's inner knees from pressing onto each other d. avoid using pillows to elevate the patient's legs e. avoid placing the patient in positions that increase stress on bony prominences
a, c, e
explain the second phase of the nurse patient helping relationship, working
contract of plan to achieve goals, collaborate with other health care providers and therapeutic communication
Which conditions are diagnosed more frequently in infancy and childhood than in adulthood? Select all that apply. a. spina bifida b. osteoporosis c. osteoarthritis d. cerebral palsy e. rheumatoid arthritis
a, d
The nurse is caring for a postsurgical patient. During a follow-up visit, the nurse finds that the patient has an infection at the surgical site. Which findings are consistent with the nurse's conclusion? Select all that apply. a. increase in pain b. absence of pulse c. tingling sensation d. increase in drainage e. elevation in temperature
a, d, e
What actions should the nurse take to assess whether a patient with a left above-the-knee amputation has adequate lower extremity circulation to the stump? (Select all that apply.) a. Palpate the stump for warmth. b. Assess pedal pulses bilaterally. c. Evaluate the left popliteal pulse rate. d. Inspect the stump and right leg for color. e. Check the left femoral pulse for strength.
a, d, e
transmission-based precautions
control of infections among pts w known or suspected infections caused by pathogens of epidemiologic significance
A nurse caring for an infertile couple learns that the couple is experiencing symptoms of chlamydia. Which statements by the nurse about chlamydia are appropriate? Select all that apply. a. it affects the genitourinary tract b. there is no cure for this disorder c. it does not cause ectopic pregnancy d. the rectum is resistant to chlamydia infection e. it may cause infection of the eyes and lungs in newborns
a, e
A nurse is educating a couple about sexually transmitted infections. Which sexually transmitted infections cannot be cured? Select all that apply. a. herpes b. syphilis c. chlamydia d. gonorrhea e. human papillomavirus infection
a, e
The nurse is trying to assess a patient's risk of osteoporosis. The nurse knows that the following groups have the highest incidence of osteoporosis. Select all that apply. a. Asian females b. White males c. American Indian males d. African-American males e. Postmenopausal women f. Patients who had fractures in the past
a, e, f
all newborns are ______________ breathers
abdominal
range of motion: fingers spread fingers apart
abduction
range of motion: hip moving leg laterally
abduction
range of motion: shoulder raise arm to side position above head with palm away from head
abduction
range of motion: thumb extending thumb laterally
abduction
range of motion: toes spread toes apart
abduction
what is critical thinking
ability to apply knowledge and experience to identify pt problems and to direct clinical judgment and actions
amenorrhea
absence of menses
injuries to the skin involving infants and children are recognized as signs of ____
abuse
what is the most common skin concern in adolescences
acne
what are common skin lesions in adolescents
acne due to increased sebaceous activity
which communication technique conveys genuine interest in what the pt has to say? 1. active listening 2. sitting close to the pt 3. maintaining professional dress and conduct 4. holding the pts hand during the interview
active listening
what are the 2 types of pain
acute vs chronic
range of motion: fingers bring fingers together
adduction
range of motion: hip moving leg back to medial position
adduction
range of motion: shoulder lower arm sideways and across body as far as possible
adduction
range of motion: thumb move thumb back to normal position
adduction
range of motion: toes bring toes together
adduction
during an interview, an elderly patient tells the nurse that she has periodic problems in keeping her balance. the nurse asks her what she is doing when the episodes occur. what area of the symptom analysis is the nurse pursuing with this question? 1. severity 2. frequency 3. aggravating factors 4. location
aggravating factors
personal/psychosocial history
air pollution home allergens HVAC system hobbies travel
loss of pigmentation in the eyes, skin and hair
albinism
explain the third phase of the nurse patient helping relationship, termination
alerting pt of closure, evaluating outcomes, transitioning pt care to care giver
pruritus is can be caused by
allergy, exposure to chemicals, infestation (scabies, lice, insect bites) or can be systemic disease
permanent or temporary hair loss
alopecia
doppler
amplifies sound
what is an example of phantom pain
amputees, people lose a part of their limb but they still feel pain from the limb that is no longer attached to their body
Value Judgement
an assessment of something as good or bad in terms of one's standards or priorities
authoritarian
an attitude that the nurse knows better than the pt what is in the pts best interest
what is a synarthroidal joint
an immovable joint
how can the nurse best describe heart failure to a client? 1. a cardiac condition caused by inadequate circulating blood volume 2. an acute state in which the pulmonary circulation pressure decreases 3. an inability of the heart to pump blood in proportion to metabolic needs 4. a chronic state in which the systolic blood pressure drops below 90 mm Hg
an inability of the heart to pump blood in proportion to metabolic needs
7 locations of vascular sounds
aorta, 2 renal, 2 iliac, 2 femoral
hair, nails, and glands are known as _____ which are formed at the junction of the epidermis and dermis
appendages
explain gordons functional health patterns
areas of function: 1. health perception 2. nutritional/metabolic 3. elimination 4. activity/exercise 5. cognitive/perceptual 6. sleep/rest 7. self-perception 8. role/relatoinship 9. sexuality/reproductive 10. coping/stress tolerance 11. value/belief
range of motion: foot turn sole of foot laterally
eversion
cyanosis in dark skinned patients
ashen-gray color; mostly seen in conjunctiva of the eye, oral mucous membranes, and nail beds
how do you assess mental health in children
ask about school violence and household violence
how do you assess mental health in adolescents
ask about school violence, household violence, self-esteem, what you do for fun, stress-management techniques
reflection
asking a question to clarify a phrase or a sentence, encouraging elaboration by the pt and indicating interest in getting more info
what are some examples of non therapeutic communication
asking why Qs, close ended Qs, changing the subject, false reassurance, giving advice, stereotypical, approval/disapproval, agreement/disagreement, excessive self-disclosure, comparing pt experiences, terms of endearment, being defensive
the nurse receives a telephone call from the post-anesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to take which action first on arrival of the client?
assess the potency of the airway
what is the snellen test
assess vision for distance
what is the rosenbaum (jaeger) test
assesses near vision
what are the elements of APIE
assessment, problem, intervention, evaluation
Landau reflex
at 3 months of age, baby raises head and arches their back, as in a swan dive. persists unti 1 1/2 years of age. If absent suggest motor dev problems- CP and MR- Low Tone or floppy child
tuning fork
auditory screening and vibratory sensation
older adult temperature
avg 97.2 degrees F - due to decreased metabolism and less physical activity
A 35-year-old woman comes to the clinic for her general health checkup. She is the mother of a 6-year-old girl. The patient wants to know about various nonprescriptive methods of contraception. Which method of contraception does not require a prescription and can be independently taught by the nurse? a. intrauterine device b. condom c. vaginal ring d. subdermal implant
b
A female patient says to the nurse, "I experience severe pelvic pain during intercourse." Which condition would the nurse infer from the patient's statement? a. vaginismus b. dyspareunia c. anorgasmia d. amenorrhea
b
A nurse is managing wound care for a patient with a stage III pressure ulcer on the elbow. The nurse cleans the area and removes all the dead, nonviable tissue from the wound. Which term is used to describe this process? a. irrigation b. debridement c. hemostasis d. cleansing
b
A parent of a 3-year-old child reports to the nurse, "It embarrasses me when my child explores his body parts in front of everyone." Which nursing response is best ? a. isolate the child from others for some time b. provide the necessary guidance for the child c. consult with the health care provider d. punish the child appropriately for such behavior
b
A patient complains of her jaw popping when chewing. Which examination techniques are appropriate for the nurse to use with this patient? a. Inspecting the musculature of the face and neck for symmetry b. Observing the range of motion of and palpating each temporomandibular joint for movement, sounds, and pain c. Asking the patient to move her chin to her chest, hyperextend her head, and move her head from the right side to the left side d. Asking the patient to open her mouth as widely as possible and inspecting the lower jaw for redness, edema, or broken teeth
b
A patient complains of pain and clicking in the jaw with movement. These symptoms are consistent with: a. gout in the jaw. b. temporomandibular joint syndrome. c. rheumatoid arthritis of the jaw. d. bursitis of the temporomandibular joint.
b
A patient tells the nurse that her stools have bright red blood in them. The nurse suspects which problem? a. Gallbladder disease b. Hemorrhoids c. Rectal polyps d. Upper intestinal bleeding
b
A patient who has been on bed rest for several days prepares to walk with assistance. Upon standing, the patient's blood pressure changes from 120/80 to 96/68 mm Hg, and heart rate changes from 88 to 112 bpm. Based on these findings, the nurse knows that the patient is experiencing which condition? a. rebound hypertension b. orthostatic hypotension c. dysfunctional proprioception d. disuse osteoporosis
b
A patient with a missed menstrual period and nausea has which signs and symptoms of pregnancy? a. Questionable b. Presumptive c. Probable d. Positive
b
A pregnant patient in her sixth month asks the nurse why her breasts are getting so big. The nurse's best response is, "The breasts enlarge during pregnancy because of": a. increased fat deposits within the breast tissue b. an increase in the size and number of lactiferous ducts and breast alveoli c. engorgement of blood vessels as a result of increased vascularization d. increased pigmentation of the areolae and protrusion of the nipple
b
A pregnant patient who is worried about having a second caesarean delivery is told by the nurse, "You likely won't require a caesarean delivery this time" in order to reduce the patient's anxiety. Which thought process is the nurse using? a. personal bias b. illogical thinking c. open mindedness d. erroneous assumption
b
A woman in her seventh month of pregnancy reports that her gums bleed easily. What is the significance of this data? a. this is a common finding and is caused by elevated estrogen levels b. this is a common finding and is caused by increased vascularity and proliferation of the gums c. this is an abnormal finding and indicates a risk of hemorrhage d. this is an abnormal finding and indicates gum atrophy
b
During a health history interview, a patient reports a painless, solid mass on the anterior aspect of one testicle. Which condition would the nurse suspect in this patient? a. inguinal hernia b. testicular cancer c. sexually transmitted disease d. undescended testicle
b
In assessing the mood of older adult patients, a nurse documents which finding as abnormal? a. Sadness and grief after returning from the funeral of a long-time friend b. Depression that interferes with the ability to perform activities of daily living c. Frustration about rearranging the day's schedule to attend a grandson's birthday party d. Crying about the unexpected death of a pet that had been with the family 12 years
b
On inspection of the eye of an 82-year-old woman, the nurse notes which finding as normal? a. Opaque coloring of the lens b. Clear cornea with a gray-white ring around the limbus c. Dilated pupils when looking at an item in her hand d. Impaired perception of the colors yellow and red
b
The edges of a patient's appendectomy incision are approximated, and no drainage is noted. Which type of healing would be applied? a. granulation b. primary intention c. tertiary intention d. secondary intention
b
The nurse asks an elderly patient to get out of the bed slowly, sit, and then stand up to prevent orthostatic hypotension. Which rationale explains the purpose of giving these instructions to the patient? a. to develop short term memory b. to warm up the core body temperature c. to improve the bodys protective barrier d. to avert falls from blood pressure changes
b
The nurse begins the assessment of patient breath sounds and notes diminished breath sounds at the base of the right lung. What action should the nurse take next? a. Refer the patient for a chest x-ray. b. Listen to the base of the patient's left lung. c. Notify the patient's primary care provider. d. Palpate the patient's lung fields bilaterally.
b
The nurse enters a patient's room, and the patient asks if he can get out of bed and transfer to a chair. The nurse takes precautions to use safe patient handling techniques and transfers the patient. This is an example of which physical care technique? a. indirect care measure b. protecting a patient from injury c. meeting the patients expressed wishes d. staying organized when implementing a procedure
b
The nurse explains that a Pap test involves the provider taking a sample of: a. vaginal discharge. b. endocervical cells. c. cervical tissue. d. uterine tissue.
b
The nurse is making rounds with the primary health care provider, who prescribes cold therapy. Which adaptation is the effect of cold therapy? a. vasodilation b. decreased pain c. wound debridement d. decreased joint stiffness
b
The nurse is performing a skin assessment on a patient in pain. Which skin layer contains sensory fibers that react to touch, pain, and temperature? a. The epidermis b. The dermis c. The hypodermis d. The subcutaneous tissue
b
The nurse is teaching a group of adolescents about the use of condoms. Which statement made by a learner indicates the need for further teaching? a. i should check the expiration date found b. i should use oil base lubricants along with the condoms c. i should not reuse a condom after sexual intercourses d. i should use condoms made of laxtex or polyurethane
b
The nurse observes multiple red circular lesions with central clearing that are scattered all over the abdomen and thorax. How does the nurse document the shape and pattern of these lesions? a. Gyrate and linear b. Annular and generalized c. Iris and discrete d. Oval and clustered
b
The patient tells the nurse that she has clay-colored stools. Stool of this color results from: a. intestinal tract bleeding. b. lack of bile pigment. c. excessive dietary beef. d. insufficient fluid intake.
b
The student nurse is studying the changes a woman goes through during pregnancy. The student nurse knows that which body system undergoes the most dramatic physiologic changes during pregnancy? a. the skin b. the cardiovascular system c. the urinary system d. the gastrointestinal system
b
What is the definition of proprioception? a. orientation to time, place, and person b. awareness of posture and movement c. perception of pressure over the palmar and plantar surfaces d. perception of abnormal thermal sensation on the skin
b
Which assessment finding is most commonly observed in patients who have suffered strokes? a. spasticity b. hemiplegia c. paraplegia d. quadriplegia
b
Which body system controls balance? a. musculoskeletal b. nervous c. pulmonary d. cardiovascular
b
Which condition is most commonly associated with damage to the lower spinal cord? a. hemiparesis b. paraplegia c. quadriplegia d. hemiplegia
b
Which finding does the nurse recognize as abnormal when examining a male patient? a. Testes that are palpable and firm within the scrotal sac bilaterally b. Discharge from the penis when the glans is compressed c. Foreskin that lies loosely over the penis d. Glans a lighter skin tone than the rest of the penis
b
Which finding of a preschooler during a cardiovascular system examination is abnormal? a. Heart rate of 106 beats/min b. Failure to gain weight because of fatigue while eating c. Continuous low-pitched vibration heard over the jugular vein d. Pulse increasing on inspiration and decreasing on expiration
b
Which mineral supplement is most likely to be included in the medication list for a patient with osteoporosis? a. zinc b. calcium c. sodium d. iron
b
Which statement regarding the comparison of the circumference between the right and left extremities is true? a. Measurements between the right and left sides should be identical. b. Measurement differences are less than 1 cm. c. Measurement differences are within 2 cm. d. Measurement differences are within 2 inches.
b
While taking the health history of a 23-year-old female patient, the nurse considers risk factors for STD. Which data from the patient suggest a need for patient education? a. She has been in a monogamous sexual relationship for 2 years; she uses a condom to prevent pregnancy. b. She has been sexually involved with one man for the last 2 weeks; she uses spermicidal gel to prevent pregnancy. c. She has a Pap test each year and the results have been negative. d. She uses oral contraceptives to prevent pregnancy.
b
While testing a patient's bicep muscle strength, the nurse applies resistance and asks the patient to perform which motion? a. Extension of the arm b. Flexion of the arm c. Adduction of the arm d. Abduction of the arm
b
the nurse is explaining the appropriate methods for measuring an accurate temperature to an unlicensed assistive personnel (UAP). which method, if noted by the UAP as being an appropriate method, indicates the need for further teaching a) taking a rectal temperature for a client who has undergone nasal surgery b) taking an oral temperature for a client with a cough and nasal congestion c) taking an axillary temperature for a client who has just consumed hot coffee d) taking a temporal temperature on the neck behind the ear for a client who is diaphoretic
b
which factor does the braden scale evaluate for? a. skin integrity at bony prominences, including any wounds b. risk factors that place the patient at risk for skin breakdown c. the amount of repositioning that the patient can tolerate d. the factors that place the patient at risk for poor healing
b
the nurse assess the vital signs of a 12 month old infant with respiratory infection and notes the respiratory rate is 35 breaths/minute. on the basis of this finding, which action is the most appropriate a) administer oxygen b) document the findings c) notify the health care provider d) reassess the respiratory rate in 15 minutes
b 35 breaths/minute is normal for a 12 month old
what is therapeutic communication
interactive process b/w nurse and client that helps the client overcome temporary stress
bathing, toileting, eating, and ambulating are all which activities
basic activities of daily living (BADLs)
audioscope
basic screening for hearing acuity
range of motion: hip turning knee inward
internal rotation
A 36-year-old man is admitted to the hospital following a motor vehicle accident. He has sustained multiple injuries on the forehead, right elbow, and left knee. On his forehead, there is a full-thickness loss of skin. The patient is given first aid and is treated with antibiotics. Arrange the phases of the healing process in appropriate order. a. maturation phase b. inflammatory phase c. proliferative phase
b, c, a
A 50-year-old male patient comes for a follow-up visit a few months after a myocardial infarction. The nurse plans to interview the patient to assess his sexual health using the PLISSIT model. Which components are included in the PLISSIT model of assessment? Select all that apply. a. palliation b. permission c. limited information d. specific suggestions e. intravenous therapy
b, c, d
A patient presents with decreased libido, depression, and difficulty coping. Which nursing interventions would be helpful for the patient? Select all that apply. a. formulate a nutrition plan for the patient b. assess the causes of coping difficulties c. help the patient to set realistic goals d. encourage the patient to express the feelings e. explain to the patient about the condoms
b, c, d
The nurse is caring for a patient who has received the medication haloperidol. Which side effects would the nurse expect in the patient? Select all that apply. a. vaginal dryness b. erectile dysfunction c. loss of sexual desire d. ejaculation dysfunction e. increased testosterone levels
b, c, d
Which activities are examples of anaerobic exercise? Select all that apply. a. walking b. heavy weight lifting c. squat jumps d. fast stair climbing e. moderate swimming
b, c, d
what does it mean if your stool is pale yellow
malabsorption syndrome
how to we avoid stereotyping
be culturally competent, but know that everyone that defines themselves within a certain culture, does not follow the same practices and have the same belief system. ask question on their beliefs and cater to their healthcare needs
The nurse is assessing the housing needs of an older adult with severe arthritis who has recently undergone knee replacement surgery. Which characteristics of a dwelling would be most appropriate for this patient? Select all that apply. a. multiple pets b. single level home c. smooth shiny flooring d. dwelling with no exterior steps e. many throw rugs
b, d
Which nursing interventions promote lung expansion in an immobile patient? Select all that apply. a. range of motion exercises b. routine coughing c. kegel exercises d. incentive spirometry e. deep breathing exercises
b, d, e
Which parts belong to the external female reproductive system? Select all that apply. a. uterus b. clitoris c. vagina d. mons pubis e. labia majora
b, d, e
Arrange the assessments in the order a pregnant patient would receive them, beginning with prenatal screening and continuing through the third trimester. a. obtain a vaginal smear for group B streptococci b. check for human immunodeficiency virus (HIV), neissseria gonorrhoeae, and human papillomavirus (HPV) c. test for gestational diabetes d. screen for any neural tube defects and trisomy 21 e. get a tuberculin skin test
b, d, e, c, a
paralinguistic communication is
nonverbal messages (e.g., gestures, eye contact, facial expressions)
state the infantile reflex: stroke the lateral surface of infants sole and the infant will fan toes
babinski
skin conditions such as cellulitis, impetigo, folliculitis, and abscesses are caused by
bacterial infections
A nurse understands that value clarification is a technique useful in therapeutic communication because initially it helps clients do what? 1. become aware of their personal values 2. gain information related to their needs 3. make correct decisions related to their health 4. alter their value systems to make them more socially acceptable
become aware of their personal values
interrupting
becoming impatient and not allowing the pt to finish sentences
responsibility
being reliable and dependable m
listen to vascular sounds using ______ side of stethoscope
bell
removal of a sample of cells to detect skin cancer
biopsy
what is the age range of pediatric nursing
birth through adolescence
neonate/newborn
birth-28 days
woods lamp
black light effect, detects fungus
woods light
black light used to test for infectious organisms and proteins
spider bites from what two spiders can cause significant symptoms
black widow or brown recluse
explain the indirect percussion technique for a physical assessment
both hands and performed by multiple different methods
what are examples of presumptive signs and symptoms of pregnancy
breast fullness/tenderness, amenorrhea, nausea and vomiting, urinary frequency, quickening (fetal movement)
explain a focused assessment
brief individualized pt exam, may be conducted when there is a change in pt condition
metacommunication is
broad term that refers to all factors that influence communication
turbulent blood flow (swishing) outside of the heart that can lead to aneurysm
bruit
tension due to fluid content
bullae
sacs containing synovial fluid that provide lubricant for the shoulder and knee joints are known as
bursae
. Which finding is an expected age-related change for a woman 80 years old? a. Kyphosis b. Back pain c. Loss of height d. Depression
c
A 48-year-old woman asks the nurse how to best protect herself from excessive sun exposure while at the beach. Which response would be most appropriate? a. "Limit your time in the sun to 5 minutes every hour." b. "Wear a wet suit that covers your arms and legs." c. "Apply a waterproof sunscreen (SPF 15 or higher) to exposed skin surfaces; reapply at least every 2 hours." d. "Apply sunscreen with a minimum SPF 50 to all skin surfaces before leaving for the beach; this will provide all-day coverage."
c
A nurse is using the Braden Scale. Which characteristic about a patient is the nurse assessing? a. perception of pain b. fall risk c. risk for skin breakdown d. risk of venous thrombosis
c
A patient comes to the clinic for a skin check. Which finding by the nurse indicates a need to further investigate a lesion? a. The lesion is dark brown. b. The lesion has been present for 20 years. c. The lesion bleeds easily when it is touched. d. The lesion is slightly raised and circumscribed.
c
A patient has edema and redness of the skin surrounding the nail on his right index finger. Which data elicited from his history best explains this condition? a. He has a family history of liver disease. b. There has been a scabies outbreak among his family members. c. He has a new full-time position as a dishwasher at a local restaurant. d. He had several warts removed from his hands 2 years ago.
c
A patient is concerned because the dermatologist diagnosed macules all over the skin. The patient asks the nurse what could be causing this? The nurse's best response is: a. "Macules need to be watched closely for signs of skin cancer." b. "Macules are warts and should be removed." c. "Macules are freckles are considered normal on the skin." d. "You have an infection and will need an antibiotic."
c
A pregnant patient in her first trimester is complaining of nausea. The patient asks why she feels so sick. The nurse explains that anorexia and nausea are common to the first trimester of pregnancy because of which of the following? a. low iron levels b. nocturia c. elevated levels of human chorionic gonadotropin d. heartburn and constipation
c
A woman comes to the clinic for a general health checkup. The patient wants more information about intrauterine devices (IUDs). Which information would the nurse include when teaching the patient about IUDs? a. it is an oral medication to be consumed regularly b. it is a surgery in which fallopian tubes are ligated c. it is a copper or plastic contraceptive device that is inserted in the uterus through the cervical opening d. it is a round rubber dome that is inserted in the vagina with spermicide and acts as barrier during intercourse
c
After surgery the patient with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which corrective intervention should the nurse do first? a. allow the area to be exposed to air until all drainage has stopped b. place several cold packs over the area, protecting the skin around the wound c. cover the area with sterile, saline-soaked towels and immediately notify the surgical team; this is likely to indicate a wound evisceration d. cover the area with sterile guaze, place a tight binder over it, and ask the patient to remain in bed for 30 minutes because this is a minor opening in the surgical wound and should reseal quickly
c
An adolescent tells a nurse that, while he was riding in a friend's car, the friend was stopped by the police for driving while intoxicated. Which assessment tool would be most appropriate to use with this adolescent? a. Faces Pain Scale b. Pediatric Symptom Checklist (PSC) c. Guidelines for Adolescent Prevention (GAP) d. Oucher Scales
c
During an examination the nurse palpates the Skene's glands. Which technique best describes this process? a. Exerting pressure over the clitoris, slide the finger downward (posteriorly) toward the vaginal opening. b. Palpate the fourchette and slide the finger forward (anteriorly) toward the vaginal opening. c. Exert pressure on the anterior vaginal wall and slide the finger outward toward the vaginal opening. d. Grasp the labia majora between the index finger and thumb and milk the labia outward
c
During examination of a patient's neck with the bell of the stethoscope, the nurse identifies a carotid bruit. When are bruits audible in the neck? a. When jugular vein distention is present b. During normal examination of the neck c. When the carotid artery is partially occluded d. With complete occlusion of both carotid arteries
c
The nurse is assessing a 72-year-old's spinal column. Which spinal finding would be considered normal for a 72-year-old patient? a. Meningocele b. Myelomeningocele c. Kyphosis d. Scoliosis
c
The nurse is assessing a newborn and hears a click when the Barlow-Ortolani maneuver is performed. What would this finding indicate? a. An indication of Erb's palsy b. A possible indication of spina bifida c. An indication of congenital hip dislocation d. A normal finding in the newborn
c
The nurse is assessing a patient's internal rotation of the shoulder joint. How should the nurse direct the patient? a. "Place your right hand behind the left side of your head." b. "Elevate your right arm over your head." c. "Place your right hand against the small of your back." d. "Rotate the palm of your hand up and down."
c
The nurse is assessing an African-American patient for cyanosis. Cyanosis in dark pigmented skin appears as a(n): a. yellowish-green skin. b. deeper tone of brown or purple. c. Ashen gray color to the skin. d. cluster of dark spots over the skin surface.
c
The nurse is assessing the risks of colorectal cancer for a group of patients. Which patient has a known risk factor for colorectal cancer? a. Steven, a 21-year-old college student who is a vegetarian b. Marie, a 22-year-old mother who has multiple hemorrhoids c. Susan, a 38-year-old female with a 15-year history of ulcerative colitis d. Jack, a 40-year-old man with frequent constipation
c
The nurse is caring for a child with quadriplegia and observes that the child shows interest in playing computer games. Which device can help the child engage in this activity? a. eyeglasses b. hearing aid c. voice activated computer d. power operated wheelchair
c
The nurse is caring for a pregnant patient who is nervous about having a cesarean delivery. The nurse says, "Don't worry. You may not need a cesarean section." Which action is the nurse performing? a. acting defensively b. advising the patient c. giving false reassurance d. giving a generalized response
c
The nurse is comparing the right and left legs of a patient and notices that they are asymmetric. Which additional data does the nurse collect at this time? a. Passively moves each leg through range of motion and compares the findings b. Observes the patient's gait and legs as he or she walks across the room c. Measures the length of each leg and compares the findings d. Palpates the joints and muscles of each leg and compares the findings
c
The nurse is counseling an adolescent on preventing sexually transmitted diseases (STDs). The patient understands this when he states, "The most common STD in the United States is__." a. gonorrhea b. syphilis c. chlamydia d. trichomoniasis
c
The nurse is palpating the fundal height of a pregnant patient. The nurse knows that to determine fundal height, one needs to measure from the__ to the top of the fundus. a. umbilicus b. perineum c. symphysis pubis d. xiphoid process
c
The nurse recognizes which symptom as commonly associated with prostate enlargement? a. Constipation b. Rectal bleeding c Weak urinary stream d. Penile discharge
c
The nurse suspects that a male patient has syphilis. Which finding suggests this diagnosis? a. A syphilis lesion on the skin in the pubic hair b. A syphilis lesion on the shaft of the penis near the base c. A syphilis lesion on the glans penis d. A syphilis lesion on the underside of the scrotal sac
c
To inspect the glans penis of the uncircumcised male, the nurse retracts the foreskin. After inspection she is unable to replace the foreskin over the glans. The nurse recognizes that this situation could potentially lead to which complication? a. Decreased sperm production b. Urinary tract infection c. Tissue necrosis of the penis d. Testicular cancer
c
Which action by a patient with a family history of macular degeneration would demonstrate use of a prevention strategy that has been found to help prevent deterioration of the macula? a. Using medicated eyedrops b. Avoiding the use of sunglasses c. Taking vitamin B6 and B12 supplements d. Minimizing dietary intake of antioxidants
c
Which action by the nurse would be most effective in determining whether a patient has muscle hypertonicity? a. Watching the patient walk to the bathroom b. Asking the patient to squeeze both hands of the nurse c. Performing passive range-of-motion exercises with the patient d. Checking the patient's spine for the presence of postural irregularities
c
Which action supports proper body mechanics when lifting or carrying objects? a. keeping the knees in a locked position b. bending at the waist c. elevating work surfaces to elbow height d. holding objects away from the body
c
Which device should the nurse use to reduce the risk of external hip rotation in a patient recovering from hip surgery? a. quad cane b. trapeze bar c. trochanter roll d. ankle foot orthotic (AFO) splint
c
Which primary contraceptive action is indicative of an intrauterine device (IUD)? a. it prevents ovulation b. it acts as a physical barrier c. it prevents fertilization d. it kills sperm cells
c
While examining the ear of an infant with an otoscope, the nurse pulls down on the ear for which reason? a. Increases the depth that the otoscope can be inserted b. Stabilizes the ear to avoid injury if the infant moves the head suddenly c. Enhances visualization of the tympanic membrane by straightening the ear canal d. Facilitates drainage of cerumen from the ear canal, allowing better visualization of inner ear structures
c
With the patient in a supine position, how does a nurse test the external rotation of the patient's right hip? a. Asking the patient to move the right leg laterally with the right knee straight b. Asking the patient to flex the right knee and turn medially toward the left side (inward) c. Asking the patient to place the right heel on the left patella d. Asking the patient to raise the right leg straight up and perpendicular to the body
c
what factor increases the risk of wound infection? a. absence of necrotic tissue b. absence of foreign body in wound c. reduced local tissue defenses d. adequate blood supply
c
which findings characterize contracture? a. muscle wasting b. altered awareness of posture and movement c. permanent fixation of a joint d. spontaneous bone break without trauma
c
what do we assess in mouth
external and internal structures
range of motion: hip turning knee outward
external rotation
A patient with multiple fractures has casts that make it difficult to move voluntarily. A nurse notices red skin in the spinal area that blanches on applying pressure. Which measures does the nurse take to decrease the risk of development of pressure ulcers in this patient? Select all that apply. a. position the patient in the most comfortable position and do not move b. cover the hyperemic skin area with a sterile dressing and apply antiseptics c. check the skin around the casts regularly for any signs of impaired skin integrity d. take care to avoid friction injuries during repositioning, bathing, or transferring of the patient e. use good hygiene techniques to ensure the patient's skin is clean and dry after bowel movements
c, d, e
range of motion: shoulder with elbow fixed, move arm until thumb is upward and lateral to head
external rotation
Which risks are associated with testicular cancer? Select all that apply. a. Multiple sex partners b. Men age 60 and over c. Men age 20 to 34 d. Family history of testicular cancer e. Cryptorchidism f. Caucasian men
c, d, e, f
A nurse is assessing a client for the use of defense mechanisms. In the presence of which defense mechanism does the client express emotional conflicts through motor, sensory, or somatic disabilities? 1. projection 2. conversion 3. dissociation 4. compensation
conversion
what consists of a diagnosis
cluster related data, etiology, signs, symptoms
what are two alternative medicine practices used by some ethnic groups on the skin
coining and cupping
_____ and mineral composition are in a state of continuous renewal to accommodate stress
collagen
during urinary assessment one should inspect:
color, symmetry, flanks
what do we assess in nose
external structures and discharge
Which complications does the nurse anticipate in the client who has blue-colored nail beds?
cardiopulmonary disease
problems linked with ligament or muscle conditions are known as
carpal tunnel syndrome
anterior bronchovesicular sounds are located..
central area of sternum
what are examples of probable signs of pregnancy
chadwicks sign (violet blue color to cervix), goodell's sign (softening of the cervix), hegar's sign (softening of lower uterine segment), positive pregnant test (hCG), serum, urine, ballottement
what are the elements of CBE
charing by exception
clubbing of nails can indicate
chronic hypoxia
chronic health history
chronic illness allergies difficulty breathing meds smoking
range of motion: hip moving leg in a circle
circumduction
range of motion: shoulder move arm in full circle; combination of all movements of ball and socket joint
circumduction
A nurse is hired to work in a healthcare facility that has a completely computer-based client information system. The nurse in charge knows that the newly hired nurse is knowledgeable about this system when the nurse says what? 1. more medication errors are made when this system is used 2. it is disappointing that nurses are not allowed to use this system 3. client information is immediately available when this system is used 4. i will have less time to provide direct care to my clients with this system
client information is immediately available when this system is used
explain problem focused nursing diagnoses
clinical judgments about undesirable human responses to health conditions or life processes
explain health promotion nursing diagnoses
clinical judgments concerning the motivation and desire to increase wellbeing and to actualize human health potential
state the infantile reflex: pinch the sole of the foot just under the toes
clonus
Normal Immature CNS Signs
clonus, tremors of jaw arms and legs, eyes crossing, brief arching and stiffness
most common skin conditions encountered
corns, dermatitis, psoriasis
high pitched cracking popping noises at end of inspiration, not cleared with cough
crackles
how do you perceive pain in a neonate (0-28 days old)
crying, increased HR, increased BP, increased respiration, decrease in oxygen saturation (level), diaphoresis (sweating), pallor (white-ish skin), and cyanosis (low oxygen, "turning blue")
Infant: Language Development
crying: 0-2months cooing:2-4months babbling: 4-18months -vocal play -reduplicated babbling -jargon initial words: 12-24months 2 word sentences: 18-24months
bluish discoloration of the skin and mucous membranes
cyanosis
A 60-year-old male patient states that he has a sore above his lip that has not healed and is getting bigger. The nurse observes a red scaly patch with an ulcerated center and sharp margins. These findings are commonly associated with which malignancy? a. Kaposi's sarcoma b. Malignant melanoma c. Basal cell carcinoma d. Squamous cell carcinoma
d
A male patient indicates that he has sex with multiple partners and that he does not use protection. The most appropriate response is: a. "Are your partners using birth control?" b. "You should avoid sex until you are married." c. "How well do you know your partners?" d. "Many men use condoms to protect themselves from disease and pregnancy."
d
A nurse administers an analgesic medication to a patient with a stage IV pressure ulcer who needs to have a dressing change. When does the nurse perform the dressing change in relation to administering the analgesic? a. before the administration b. 90 minutes after administration c. immediately after administration d. 30 minutes after administration
d
A nurse assesses a patient who comes to the pulmonary clinic. "I see that it's been over 6 months since you've been in, but your appointment was for every 2 months. Tell me about that. Also I see from your last visit that the doctor recommended routine exercise. Can you tell me how successful you have been following his plan?" Which functional health pattern in Gordon's model does the nurse's assessment cover? a. value-belief b. cognitive-perceptual c. coping-stress-tolerance d. health perception-health management
d
A nurse is caring for a patient who is a sex worker. Which sexually transmitted diseases can the patient be vaccinated against? a. human immunodeficiency virus (HIV) b. herpes c. chlamydia d. human papillomavirus (HPV) infection
d
A patient is prescribed antihypertensive therapy. Which information should the nurse provide to the patient about sexual activity? a. the patient may have delayed ejaculation b. the patients sexual desire may increase c. the medication may lessen vaginal lubrication d. the medication may cause erectile dysfunction
d
During an assessment of a young adult, the nurse notes that the patient's shoulders are uneven. Which examination would the nurse perform for further data? a. Ask the patient to rotate each shoulder to assess for range of motion. b. Ask the patient to push against the nurse's hands with his or her forearm to test muscle strength. c. Ask the patient to shrug his or her shoulders while the nurse pushes them down to test the muscle strength. d. Ask the patient to bend forward at the waist while the nurse checks the alignment of the patient's vertebrae
d
During an initial prenatal visit the nurse identifies which factor as consistent with a high-risk pregnancy? a. Patient is 18 years old. b. Patient height is 5 feet 4 inches. c. Birth weight of infant with last pregnancy was 2800 g. d. Patient smokes one-half pack of cigarettes a day.
d
How does the nurse determine if a patient's musculoskeletal examination is normal? a. By reading the examination findings documented in the patient's chart b. By comparing findings from other patients in the same age group c. By reading descriptions in health assessment books d. By comparing the patient's left side with the right side
d
On assessment of the neurologic status of a 4-month-old infant, the nurse notes which finding as abnormal? a. The infant abducts and extends arms and legs when startled. b. When the infant's sole is touched, the toes flex tightly in an attempt to grasp. c. When stroking the infant's foot from sole to great toes, there is fanning of the toes. d. The infant steps in place when held upright with feet on a flat surface
d
The nurse assesses that a woman in her eighth month of pregnancy has a wide thoracic cage. What best explains this finding? a. she may have a lung disease such as emphysema b. she may be hypoxic and may require oxygen c. this is a finding seen only in women carrying multiple fetuses d. this is considered a normal finding with advanced pregnancy
d
The nurse fits elastic stockings on a patient following major abdominal surgery. The nurse explains to the patient that the stockings help prevent which condition? a. varicose veins b. muscular atrophy c. joint contractures d. deep vein thrombosis
d
The nurse is assessing a patient for nail clubbing. Where should the nurse focus the exam? a. The width of the nail base b. The color of the nail c. The thickness of the nail d. The angle of the nail base
d
The nurse is assessing a patient's skin turgor. Skin turgor is assessed by: a. auscultating the skin to note the presence of motility sounds. b. pressing on the skin and observing the depression. c. stretching the skin and observing for a degree of flexibility. d. pinching the skin and watching the skin return to place.
d
what do we assess in ears
external structures, hearing, discharge
alopecia
extreme hair loss
The nurse is caring for a patient who has undergone ankle surgery. The primary health care provider places a Jackson-Pratt device in the patient. Which nursing action by the nurse indicates a need for further teaching? a. recompresses the device after emptying b. wears gloves while emptying the reservoir c. uses a medication cup to collect the drainage d. places the container above the level of the wound
d
The nurse is developing a teaching plan for a pregnant patient. One of the interventions in the plan of care is to wear sunscreen and avoid the sun. What is the rationale for the recommendation? a. decreased blood flow to the hands and feet causes occasional cyanosis b. a decreased number of sebaceous lands cause conservation of body heart c. thickness of the skin decreases d. pigmentation of the skin increases
d
The nurse is performing a skin check on a patient. In which age group is seborrheic keratosis an expected finding? a. Newborns b. Young children c. Adolescents d. Older adults
d
The nurse makes an introduction and explains the procedure of wound care to the patient. The nurse then performs hand hygiene and checks the patient's treatment plan. Which specific intervention facilitates the patient's cooperation with wound care? a. making an introduction b. performing hand hygiene c. checking the care plan of the patient d. explaining the wound care procedure
d
The nurse notes the presence of ptosis when assessing an adult patient's eyes. Which potential cause would be considered of most concern, requiring further evaluation as soon as possible? a. Loss of skin elasticity b. Levator muscle weakness c. Congenital ocular abnormality d. Oculomotor cranial nerve III paralysis
d
The nurse notes which finding as abnormal during a thoracic assessment of an older adult? a. A skeletal deformity affecting curvature of the spine b. Shortness of breath on exertion c. An increase in anteroposterior diameter d. Bronchovesicular breath sounds in the peripheral lung fields
d
The nurse testing the patient's muscle strength finds that the patient has full resistance to opposition. Using Table 14-3, how would this finding be documented? a. Poor or 2/5 b. Fair or 3/5 c. Good or 4/5 d. Normal or 5/5
d
The nurse that is examining a patient with normal muscle strength would document Grade __. a. 0 b. 1 c. 3 d. 5
d
What is an expected finding of the newborn's vision that the nurse teaches the parents? a. Small tears will be noted when their newborn cries. b. Peripheral sight does not develop until age 3 or 4 months. c. The newborn can only distinguish the colors of blue and green. d. The newborn is nearsighted and cannot see items unless they are close.
d
What is the nurse assessing when measuring from the patient's symphysis pubis to the top of the fundus? a. Fetal development b. Fetal lie and position c. Attitude of the fetus d. Gestational age
d
When a nurse asks a patient to place the right arm behind the head, the nurse is testing for which range of motion? a. Flexion of the elbow b. Hyperextension of the shoulder c. Internal rotation and adduction of the shoulder d. External rotation and abduction of the shoulder
d
When examining a 16-year-old male patient, the nurse notes multiple pustules and comedones on the face. The nurse recognizes that increased activity of which cells or glands produce these manifestations? a. Epidermal cells b. Eccrine glands c. Apocrine glands d. Sebaceous glands
d
When examining the genitalia of a 3-year-old boy, which position is ideal? a. Prone position with legs flexed in a frog leg position b. Supine position with knees spread and ankles spread apart c. Lithotomy position with knees and ankles spread apart d. Sitting position with knees spread and ankles crossed
d
When repositioning an immobile patient, the nurse notices redness over a bony prominence. Which condition is indicated when a reddened area blanches on fingertip touch? a. a local skin infection requiring antibiotics b. sensitive skin that requires special bed linen c. a stage III pressure ulcer needing the appropriate dressing d. blanching, hyperemia, indicating the attempt by the body to overcome the ischemic episode
d
Which are expected findings of a newborn's respiratory assessment? a. Thoracic breathing b. A 1:2 ratio of anteroposterior-to-lateral diameter c. Flaring of the nares noted on inspiration d. Bronchovesicular breath sounds in the peripheral lung fields
d
Which data collected from the history of a 32-year-old female patient should be followed with a symptom analysis? a. Has never had a mammogram. b. Experiences light to moderate bleeding during menstrual cycle. c. Periods began at age 12; has never been pregnant. d. Has pelvic pain and vaginal discharge.
d
Which disorder is an example of a vascular lesion? a. Dermatofibroma b. Vitiligo c. Sebaceous cyst d. Port wine stain
d
Which patient condition increases the risk of osteomyelitis? a. Severe gout b. Rheumatoid arthritis (RA) c. Severe osteoporosis d. An open fracture of the radius
d
Which process occurs during the proliferative phase of wound healing in a patient? a. homeostasis b. wound cleaning c. scar tissue formation d. granulation tissue formation
d
Which topic would the nurse discuss with senior citizens about the leading cause of injury in older adults? a. drowning b. illicit drug use c. work related hazards d. complications from falls
d
a client receiving parenteral nutrition (PN) suddenly develops a fever. the nurse notifies the health care provider (HCP) and the HCP initially prescribes that the solution and tubing be changed. what should the nurse do with the discontinued materials? a) discard them in the unit trash b) return them to the hospital pharmacy c) save them for the manufacturer d) prepare to send them to the laboratory for culture
d
a staff nurse is precepting a new graduate nruse and the new graduate is assigned to care for a client with chronic pain. which statement, if made by the new graduate nurse, indicates a need for further teaching regarding pain management? a) i will be sure to ask my client what his pain level is on a scale of 0 to 10 b) i know that i should follow up after giving medication to make sure its effective c) i know that pain in the older client might manifest as sleep disturbances or depression d) i will be sure to cue in t any indicators that the client may be exaggerating their pain
d
which sequence best identifies the order in which the nurse should complete an abdominal assessment? a. Inspection, palpation, percussion, auscultation b. Auscultation, inspection, palpation, percussion c. Auscultation, palpation, percussion, inspection d. Inspection, auscultation, palpation, percussion
d
reddened skin color, dusky coloring of lips and feet, fine hair covering skin, asymmetric head due to molding, edema to eyelids, symmetric ears, pink moist mucosa, rounded thorax, faster HR and RR, equal movement and length of extremities
expected newborn findings
range of motion: elbow straighten elbow by lowering hand
extension
what are nails
epidermal cells converted to hard plates of keratin
opthalmoscope
eye exam
the _____ is a layer which is highly vascular, regulates temperature, and contains nerve fibers that provide reactions to touch, pain, and temperature
epidermis
the _____ is the outermost layer and provides no blood supply
epidermis
the outermost layer of the skin
epidermis
skin is composed of what 3 layers
epidermis - avascular, provides pigment dermis - vascular subcutaneous layer (hypodermis) - anchor for upper layers
necrotic tissue
eschar
ecchymosis (bruise) in light skinned patients
dark red, purple, yellow, or green color, depending on bruise age
what is a problem-based/problem-focused assessment
data limited in scope to a specific problem
what are the elements of DAR
data, action, response
ecchymosis (bruise) in dark skinned patients
deeper bluish or black tone; difficult to see unless it occurs in an area of light pigmentation
erythema in dark skinned patients
deeper brown or purple skin tone with evidence of increased skin temperature secondary to inflammation
skin temp
depends on amount of blood circulating through the dermis
thick middle layer of skin between the epidermis and the deeper subcutaneous layer
dermis
turgor
describes the skins elasticity
MSAFP
detects alpha fetal protein (trisomy 21, trisomy 18, neural tube defects)
amniocentesis
detects birth defects
EHR
developing skills for electronic documentation
listen to bowl sounds using __________ of stethoscope
diaphragm
the ___ history of a pediatric patient includes typical diet, intolerances, allergies, supplements, meal time routines, snacks, and any concerns about diet or weight
diet
mobility - pain
differentiate b/w joint pain vs bone pain vs muscle pain
transilluminator
differentiates tissue, fluid, and air in body cavity
dysmenorrhea
difficult or painful menses
petechaie in dark skinned patients
difficult to see; may be evident in the buccal mucosa of the mouth or sclera of the eye
what are the two types of percussion techniques for physical assessments
direct and indirect
what is beneficence
doing good
how do we break an awkward silence with the pt
dont! get used to silence. the pt is probably trying to find the courage to speak up about something
range of motion: ankle moving foot so toes point upward
dorsiflexion
the _____ are responsible for transporting sperm
ducts
when is a comprehensive health history performed
during hospital visit, initial clinic or home visit, or when the pt reason for seeking care is relief of generalized symptoms
what are skene's glands
during sexual intercourse, they secrete a lubricating fluid
swelling
edema
hand off/reporting
end of shift or end of day report, nurse-nurse communication
________ pulses should be felt in children
femoral
what is nonmaleficence
first, do no harm
abnormal connections between two organs or between an internal organ and through the skin
fistula
range of motion: elbow bend elbow so lower arm moves towards shoulder joints and hand is level with shoulder
flexion
range of motion: hip moving leg forward and up
flexion
range of motion: knee bringing heel toward back of thigh
flexion
range of motion: neck and cervical spine bringing chin to rest on chest
flexion
range of motion: shoulder raise arm from side position forward to position above head
flexion
range of motion: thumb moving thumb across palmar surface of hand
flexion
range of motion: toes curl toes downward
flexion
range of motion: wrist moving palms towards inner aspect of the arm
flexion
range of motion: fingers make fist
flextion
what is clinical reasoning
focus and filter clinical data to recognize what is most vs least important
small group communication
focuses on meeting established goals
what is intrapersonal communication
focuses on personal needs and can influence a persons well-being, self-talk
what is an episodic/follow up assessment
focuses on specific problems for which a pt has been receiving treatment
what are the common problems associated with bones
fractures and osteoporosis
Feeling for vibration when one says ninety nine
fremitus
scar in dark skinned patients
frequently has keloid development, resulting in a thickened, raised scar
tinea infectoins and candidiasis are lesions of a ______ nature
fungal
____ are needed for production and secretion of fluid that makes up the semen
glands
this patient has no evidence of contractility, how would you grade this and how would you record it on the lovett scale
grade: 0 lovett scale: zero (0)
this patient has evidence of slight contractility, how would you grade this and how would you record it on the lovett scale
grade: 1 lovett scale: trace (T)
this patient has complete range of motion with gravity eliminated, how would you grade this and how would you record it on the lovett scale
grade: 2 lovett scale: poor (P)
this patient has complete range of motion with gravity, how would you grade this and how would you record it on the lovett scale
grade: 3 lovett scale: fair (F)
this patient has complete range of motion against gravity with some resistance, how would you grade this and how would you record this on the lovett scale
grade: 4 lovett scale: good (G)
this patient has complete range of motion against gravity with full resistance, how would you grade this and how would you record this on the lovett scale
grade: 5 lovett scale: normal (N)
cyanosis in light skinned patients
grayish-blue tone in nail beds, earlobes, lips, mucous membranes, palms, soles of feet
chronic cough lasts
greater than 3 weeks
normal bowel sounds are
gurgling, clicking, popping
hirsutism
hair growth on upper lip chin and cheeks that becomes excessive
what is the most important action to reduce transmission of infection
hand hygiene
sphygmomanometer
has gauge to measure pressure (manometer), BF cuff, pressure bulb with valve to deflate
the nurse understands that which statement is correct regarding respiratory rates?
healthy adults breathe between 12-20 times a minute
jugular distention in adults is an indication of
heart failure
menorrhagia
heavy menses
family
helps determine patients risk for these diseases
what does it mean if your stool is bright red
hemorrhoidal or lower rectal bleeding
what are common conditions related to the spine
herniated nucleus pulposus and scoliosis
how do we assess touch
hot vs. cold, sharp vs. dull, etc
range of motion: elbow bend lower arm back as far as possible, not all elbows hyperextend
hyperextension
range of motion: fingers bend fingers back as far as possible
hyperextension
range of motion: hip moving leg behind body
hyperextension
range of motion: neck and cervical spine bending head back as far as possible
hyperextension
range of motion: shoulder move arm behind body, keeping elbow straight
hyperextension
range of motion: wrist bringing dorsal surface of hand back as far as possible
hyperextension
the _____ is a subcutaneous layer composed of fat; fatty cells help with heat regulation and provide protection against injury
hypodermis
the menstrual cycle is regulated by the _____
hypothalamus
A client is being discharged after a first-trimester aspiration abortion. Which statement indicates to the nurse that the client has understood the instructions? 1. ill be able to have sex in 4 or 5 days 2. i can switch from sanitary pads to tampons after 24 hours 3. i can expect my menstrual period to start again in 2 to 3 weeks 4. i need to call you if i have to change my pad more than once in 4 hours
i need to call you if i have to change my pad more than once in 4 hours
facilitation
includes responses such as "go on" and "uh-huh" as well as nonverbals like nodding in agreement
lordosis
increase in lumbar curve just above the buttocks
what should you consider about a pts BP
indirect way to check a pts BP is manually or automated BP machine, direct way to check a pts BP is through an arterial line
Moro reflex (aka startle)
infant startle response to sudden, intense noise or movement. When startled the newborn arches its back, throws back its head, and flings out its arms and legs. Baby's first attempts to protect himself from harm. until about 4 mos old
yellow/green sputum
infection
explain secondary data
info shared by family, friends, or other healthcare team members
tympanic membrane thermometer
infrared radiation device
temporal artery thermometer
infrared radiation device that measures temp from temporal artery
while examining a patient with an infected abdominal incision, the nurse notices that it is very malodorous. which technique does this represent? 1. inspection 2. palpation 3. auscultation 4. percussion
inspection
otoscope
inspects auditory canal and tympanic membrane
meal prepping, shopping, safe medication use, management of finances, and traveling are all which activities
instrumental activities of daily living (IADLs)
what is a problem oriented medical record (POMR)
integrates charing from the entire care team in the same section
a nurse is teaching a family from guatemala about the importance of exercise to reduce body weight. the husband asks, what exercise should we do? considering the most effective way for the nurse to respond? 1. research has shown that walking 30 minutes most days of the week is best 2. is there an exercise that you can do today for 30 minutes and add it to your daily routine? 3. if you exercise 30 minutes most days of the week, you can lose weight by your next visit 4. i have always found that resistance weight training each day for 30 min is effective
is there an exercise that you can do today for 30 minutes or add it to your daily routine
reduced blood flow
ischemia
pruritus
itching of the skin with or without a rash
The parents of a child with acute poststreptococcal glomerulonephritis ask a nurse why their child is being weighed every morning. What is the best response by the nurse? 1. its the best way to measure your childs fluid balance 2. it provides a measure of how much protein is being lost 3. the disease process is usually over when weight loss stops 4. plans for the daily caloric intake are made according to the daily weight change
its the best way to measure your childs fluid balance
a yellow hue to the skin
jaundice
what is the most common musculoskeletal symptom for which patients seek treatment
joint pain
the point where 2 or more bones come together are
joints
fidelity
keeping promises and commitments
venous hum is normal for _______, and located in the _______vein.
kids, jugular
how do you assess mental health in infants/newborns
know of the mothers OB history, what pregnancy was like, finding out the mothers background info
tissue integrity - pressure ulcers
known as bedsores or decubitus ulcers; localized to injury to the skin and underlying tissue usually over bony prominence as a result of pressure; at risk patients include those who are immobile or bed bound
range of motion: neck and cervical spine tilt head as far as possible towards each shoulder
lateral flexion
petechaie in light skinned patients
lesions appear as small, reddish-purple pinpoints
acute cough could lasts
less than 3 weeks
what is the emergency severity index (ESI) for triage
level 1 - critical life threatening level 2 - high risk, imminently life threatening level 3 - moderate risk, potentially life threatening level 4 - low risk, stable health condition level 5 - non-urgent lower risk
explain chronic pain
lifelong or long term
what holds bones to bones
ligaments
confidentiality
limits sharing private info
the internal spinchter
lined with smooth muscle and is under involuntary control
what do sebaceous glands do
lipid rich (sebum) substance that keeps the skin and hair lubricated; found everywhere but the palms and soles
while auscultating a patient's lungs, the nurse notes diminished breath sounds at the base of the right lung. What action should the nurse take next?
listen to the base of the patients left lung.
explain ausculation of a physical assessment
listening to sounds within the body
explain the head to toe model
literally cephalic to caudal
anterior peripheral vesicular sounds are located
lung fields starting from clavicles
a bite from an infected tick can give you
lyme disease
utilitarianism
maintains that behaviors are determined to be right or wrong solely on the basis of their consequences
rash in light skinned patients
may be visualized and felt with light palpation
standard electric thermometer
measurement of oral, rectal, or axillary temp
thermometer
measures body temp
pulse oximeter
measures oxygen saturation in arterial blood and pulse rate
standard precautions
measures to reduce the risk of transmitting infection from body fluids and non-intact skin
what group of people have greater chance of developing a latex allergy
medical professionals - because we use latex gloves often and the more often you use them the more likely you are to develop an allergy for latex
what should you consider about a pts respiratory rate
men and women breathe differently. men breathe from the abdomen and women breathe more thoracic
the permanent cessation of menses and is complete after a period of 1 year without menses
menopause
the five stages of the _______ cycle are: 1. menstrual 2. postmenstrual 3. ovulation 4. secretory 5. premenstrual
menstrual
menstrual cycle: stage 1
menstrual phase - days 1-4 estrogen and progestin levels decrease; triggers shedding of endometrium layers and menstrual bleeding
_____ health of the pediatric patient is affected by maternal substance abuse in pregnancy, perinatal hypoxia, neurologic illness, developmental delays, family problems, and violence witnessed
mental
communication is linguistic, paralinguistic, and
metacommunication
restatement
method of repeating what the pt said to confirm interpretation of the information
what are common skin lesions in children
milia, erythemia toxicum, diaper rash, rashes associated with allergens
_____ depends on the delivery of oxygenated blood to tissues and coordination of movement regulated by the brain, spinal cord, and peripheral nerves
mobility
state or quality of being mobile or movable
mobility
the vulva includes:
mons pubis, labia majora, labia minora, clitoris, fourchette
state the infantile reflex: you startle an infant and the infant pulls its legs and arms against trunk as if trying to protect itself
moro
skeletal muscles are attached to bones to facilitate ____
movement
see-saw breathing
movement of chest and abdomens in oppsite direction-- abnormal
the nurse is conducting an interview with jeremy, a 17 year old accompanied by his mother. which statement made by the nurse is an age-appropriate adjustment when conducting a health history with an adolescent? 1. "Jeremy, do you have a girlfriend, and if so are you sexually active yet?" 2. "Mrs. Williams, is your son sexually active yet?" 3. "Jeremy, how do you incorporate safe sex practices into your daily life?" 4. "Mrs. Williams, would you wait outside while I discuss a few things with Jeremy"
mrs. williams would you wait outside while i discuss a few things with jeremy
turbulent blood flow INSIDE the heart
murmur
atrophy
muscle wasting
what is the primary function of the _______ system is to facilitate motion; it provides support for the body, protection of internal organs, production of blood cells, and storage of minerals
musculoskeletal
what is an example of referred pain
myocardial infarction. the pain occurs in the heart but people perceive it being in the jaw, arm, or back
scar in light skinned patients
narrow scar line
death of cells, tissues, or organs
necrosis
basal cell carcinoma, squamous cell carcinoma, melanoma, and kaposi sarcoma are the most common _____ skin conditions
neoplastic
what age group has their hip joints and feet assessed for abnormalities
newborns
is palpation of lung sounds performed on newborns?
no, only inspection and vital signs
The nurse notes a black umbilicus on a 5-day-old infant. What does this finding indicate? a. The infant may have a feeding problem. b. The umbilicus is infected. c. The infant has hepatitis. d This is a normal finding.
normal finding
clear sputum
normal/allergies
rash in dark skinned patients
not easily visualized but may be felt with light palpation
to maintain tissue integrity, the body needs adequate _____ and _____ to carry nutrients to the tissue
nutrition and oxygenation
explain the first phase of the nurse-patient helping relationship, orientation
observation, interview, assessing, identifying needs, and introductions
Primitive reflexes
observed in infants and involuntary become integrated as infant gains voluntary motor control usually 6 mos
what does it mean if your stool is light tan or gray
obstruction of the biliary tract (obstructive jaundice)
Interrupting
occurs when one person stops speaking when another person starts speaking
what is an emergency assessment
occurs when time is a factor and treatment must begin immediately, triage is the form of emergency assessment
therapeutic communication is
offering self, calling pt by name, sharing observations, giving info, open ended Qs, focused comments, generalized leads, acceptance, humor, verbalizing the implied, paraphrasing, reflecting feelings, seeking clarification, summarizing, validating, etc
significant changes in what age group occur with regard to skin and hair
older adults
which age group is slower at performing range of motion exercises
older adults
range of motion: thumb touch thumb to each finger of the same hand
opposition
what should you consider about taking a pts temperature
orally: dont take pt temp for 5 mins if they've had a hot or cold beverage axillary: least reliable temp bc there is the ability of open air to circulate, we normally add a degree if we have to take the temperature this way rectally: most reliable way to check a temp
explain the body systems model
organizes data based on each body system: integumentary, respiratory, cardiovascular, nervous, etc.
what is the most common infection in children
otitis media
kyphosis
outward curvature of the thoracic spine - may alter respiratory pattern
the primary functions of the ______ include ovulation and secretion of reproductive hormones
ovaries
anterior bronchial sounds are located
over trachea (throat area)
menstrual cycle: stage 3
ovulation - day 13 or 14 steep rise in estrogen and luteinizing hormone (LH); egg is expelled from follicle and drawn into fallopian tube; rise in progesterone causes thickening in uterine wall
what should you consider about a pts SpO2
oxygen is carried by hemoglobin, non-invasive clip goes on pts finger to tell us the oxygen levels in pts body
sometimes ____ is referred to as another vital sign
pain
pallor in light skinned patients
pale skin color that may appear white
pale skin tone
pallor
tissue integrity - diagnostics
patch testing, wound cultures, tissue biopsy, woods light
this type of nursing encompasses birth through adolescence
pediatric
the ____ serves the functions of excreting urine from the body and introducing sperm into the vagina during intercourse
penis
what are the external structures of the male reproductive system
penis (corpus cavernosa, corpus spongiosum, glans penis, corona, erection), scrotum (spermatic cord)
palpation
performed to assess the pts skin for texture, warmth, turgor, edema, or moisture
what is menopause
permanent cessation of menses and is considered complete after a woman has experienced an entire year with no menses
contracture
permanent fixation of joint
foot drop
permanent plantar flexion
how do you inspect pain?
physical appearance & hygiene body structure & position emotional status, mental status, and behavior body movement
range of motion: ankle moving foot so toes point downward
plantar flexion
state the infantile reflex: touch object to sole of infants foot and the toes will flex slightly downward in attempt to grasp
plantar grasp
low pitched, coarse, rubbing or grating sound, heard in inspiration/expiration
pleural friction rub
sitting
position that provides full expansion of the lungs and visualization of the upper body. infants and physically weakened patients are often unable to tolerate this position
lithotomy
position that provides maximal exposure of the genitalia. an embarrassing and uncomfortable position
knee-chest
position that provides maximal exposure of the rectal area. an embarrassing and uncomfortable position
sims
position that requires flexion of the hip and knee, improving exposure of the rectal area. difficult to tolerate for patients with joint deformities
prone
position used to assess extension of the hip joint. poorly tolerated in patients with respiratory difficulties
assertive communication
positive and negative ideas and feelings are expressed in an open and direct way
posterior vesicular sounds are located
posterior lung fields
menstrual cycle: stage 5
premenstrual phase - days 21-28 if fertilization do not occur, progesterone production decreases, estrogen levels rise, and when the thickened uterine wall begins to shed, menstruation starts again, as does the beginning of a new cycle
explain risk nursing diagnoses
risk factors that are vulnerabilities for developing negative human responses to health conditions or life processes
how do you test for balance
romberg test
what does hair consist of
root, shaft, and follicle (root and its covering)
state the infantile reflex: brush the infants cheek near corner of mouth and infant will turn head toward stimulus and open mouth slightly
rooting response (awake)
visual acuity charts consist of 2 kinds. what are they
rosenbaum chart for near vision and snellen chart for distance vision
range of motion: neck and cervical spine turning head as far as possible to left and right
rotation
wound cultures
sample wound for bacterial or fungal growth
a skin condition associated with a mite and is highly contagious is known as
scabies
the _____ is the pouch that contains the testis, epididymis, and spermatic cord
scrotum
what are bartholin's glands
secrete a mucoid material into the vaginal orifice for lubrication during sexual excitement
what do apocrine sweat glands do
secretion begins at puberty and is influenced by hormones; odorless fluid is secreted containing protein, carbs, and other substances
menstrual cycle: stage 4
secretory phase - days 15-20 after ovulation, FSH and LH decline; egg moves into uterus; secretion of progesterone rises and estrogen declines; uterine wall continues to thicken
what is intrapersonal communication
self talk
autonomy
self-determination, freedom
describe culturally congruent care
sensitive, creative, safe, and meaningful ways to promote the health and well being of individual people or groups and improve their ability to face death, disability, or difficult human life conditions
questions directed at the adolescent patient should be approached with _____ when discussing pubertal changes, menstruation, and sexuality
sensitivity
drainage that is pink to pale red
serosanguineous
drainage that contains clear watery fluid
serous
The nurse should auscultate the abdomen for at least __ before documenting an absence of bowel sounds. 1. 5 to 15 seconds 2. 30 seconds 3. several minutes 4. 1 hour
several minutes
interpretation
sharing conclusions the nurse has drawn from the information given, allowing the pt to confirm, deny, or revise the conclusions
explain acute pain
short term, not lasting for more than 6 months
dyspnea
shortness of breath
appendicular skeleton consists of
shoulder girdle, pelvic girdle, extremities
scoliosis
sideways "S" curve of the spine
explain objective data
signs, may be observed or measured
what is objective data
signs, observations, measurable
what are the most common patient positions
sitting and supine
the external spinchter
skeletal muscle, voluntary control, allows for control of defecation
the primary function of the _____ is to protect the body from invasion by bacteria and foreign substances
skin
patients with hemiplegia, paraplegia, or quadriplegia are at high risk for _____
skin breakdown
what is the most common cancer
skin cancer
what are common skin lesions in older adults
skin cancer increases with age and inspection of sun exposed areas
pallor in dark skinned patients
skin tone appears lighter than normal; light skinned african americans may have yellowish-brown skin; dark skinned african americans may appear ashen; specifically evident is a loss of the underlying healthy red tones of the skin
axial skeleton consists of
skull neck, ribs, sternum, trunk, pelvis
black sputum
smoke or coal dust inhalation
the bones within the skeleton provide support for ______ and ____
soft tissues and organs
oral contraceptives and _____ alter the normal vaginal flora
some antibiotics (eeek!!)
Cranial Nerve XI (11)
spinal accessory (shoulder shrug - with and without resistance)
After her child's visit to the pediatrician a mother tells the nurse that she is concerned that an antidepressant has been prescribed for her adolescent son. What is the best response by the nurse? 1. tell me more about whats bothering you 2. you need to speak with the primary healthcare provider about your concern 3. are you sure its not a medication for attention deficit disorder 4. didnt the primary healthcare provider tell you why your son needs an antidepressant
tell me more about whats bothering you
when you assess a pt, what vital signs are you checking
temperature HR (pulse) respiratory rate BP pulse oximetry (SpO2) pain weight & height
what holds muscle to bones
tendons
the primary function of _____ is to produce sperm
testes
what are the internal structures of the male reproductive system
testes and ducts (epididymis, vas deferens, ejaculatory duct, urethera), glands (seminal vesicles, prostate gland, bulbourethral gland)
percussion hammer
tests deep tendon reflexes
DEXA
tests for bone mineral density
describe cultural competence
the ability to interact with and appreciate people of different cultures and beliefs; intentional effort
Clarification
the act of making clear or understandable
Interpretation
the action of explaining the meaning of something
An infant with a congenital heart defect is being given gavage feedings. The parents ask the nurse why this is necessary. What is the best response by the nurse? 1. it limits the chance of vomiting 2. it allows the feeding to be administered rapidly 3. the energy that would have been expended on suckling is conserved 4. the quantity of nutritional liquid can be regulated better than it can with a bottle
the energy that would have been expanded on suckling is conserved
deontology
the ethical view that moral value is determined by fulfilling one's duty
this system is comprised of the skin, hair, nails, sweat glands, and sebaceous glands
the integumentary system
what is channel
the means by which a message is communicated
supine
the most normally relaxed position, providing easy access to pulse sites. difficult to tolerate for patients who get short of breath easily
pack-years
the number of packs per day multiplied by the number of years the patient has smoked
what is sender
the person who initiates the message
what is receiver
the person who receives the message
what is threshold
the point at which the pain does hit and is identified to you as pain
edema
the swelling or build up of fluid in tissue
what is verbal communication
the use of language or words spoken
the primary purposes of ______ is to carry menstrual flow from the uterus, serve as a receptive organ during intercourse, and to serve as the birth canal during delivery
the vagina
how do you assess mental health in older adults
their habits. ex. oversleeping is not normal, could indicate depression
what should you consider about taking a pts HR
there are different locations of the pulses. check for a full minute when doing HR
The nurse suspects an infant has fetal alcohol syndrome. Which assessment finding is consistent for an infant with fetal alcohol syndrome? Malformation of the ear "Moon face" Torticollis Thin upper lip
thin upper lip
what is tolerance
this can vary and is the length of time someone can tolerate their pain. some people can endure pain and now show outwardly symptoms right away
At 6/7 years old child changes from nasal breathing to..
thoracic for girls diaphragmatic for boys
The state of structurally intact and physiologically functioning epithelial tissues such as the integument (including skin and subcutaneous tissue) and mucous membranes
tissue integrity
the intactness and function of the skin, hair, and nails refers to
tissue integrity
what is the purpose of nagele's rule
to determine the estimated date of delivery
state the infantile reflex: rotate head to side while infant is supine, arms and legs should extend to which side the head is turned to while opposite arms and legs flex
tonic neck
what is the most common infection of the oropharynx in children
tonsillitis
veracity
truthfulness
active
type of listening with purpose to the spoken words and noticing nonverbals
why
type of question that can be perceived as threatening and put the pt on the defensive
open-ended
type of question that encourages a free-flowing response
close-ended questions
type of question that requires only one or two words to answer. used to gain more precise details
range of motion: wrist bend wrist laterally toward 5th finger (radial/ulnar deviation)
ulnar flexion
reproduction - diagnostics
ultrasound •5 weeks = visualization of the fetus •6 weeks = fetal heart rate activity •8 weeks = auscultated fetal heart tones •19 weeks = palpable fetal movements
what are defense mechanisms
unconscious strategies that allow an individual to decrease/avoid unpleasant circumstances
Allis sign
unequal leg length you want a NEGATIVE allis sign
posterior bronchovesicular sounds
upper center of back between scapulae
what does it mean if your stool is tarry black
upper intestinal tract bleeding or excessive iron or bismuth ingestion
the vaginal vestibule includes:
urethral meatus, vaginal introitus (vaginal opening), hymen
texture
use 2-3 fingertips, skin described as smooth, rough, supple, soft, firm, thin or thick
medical
use of this terminology can lead to confusion, misunderstanding, or embarrassment for the pt, who may not know the jargon being used
what should you consider for a pts weight and height
use the SAME scale every time, body mass index (BMI) is used to determine healthy weight, obesity, underweight, etc.
stethescope
used to ausculate sounds within the body
X-rays
used to diagnose bone abnormalities (ex. fracture)
tissue biopsy
used to diagnose malignancy (change in moles or skin abnormalities)
clarification
used to obtain more information about conflicting, vague, or ambiguous statements
tissue integrity - braden scale
used to predict pressure ulcers, the lower the score, the more at risk the patient is for a pressure ulcers *Lower the number = the greater risk for pressure ulcer development*
patch testing
used to test allergens
conforntation
used when inconsistencies are noted, require that the nurses tone of voice not be accusatory in order to be effective
explain the palpation technique of a physical assessment
using the hands to feel texture, shape, size, consistency, pulsation, or location
how do you test for coordination
using the upper and lower extremities
the _____ is a muscular organ suspended by ligaments between the bladder and the rectum
uterus
internal structures of the female reproductive tract
vagina (uterine cervix, fornix), uterus (cervix, cervical opening, corpus), fallopian tubes, ovaries
linguistic communication is
verbal exchange of messages through spoken words and written symbols
Newborn posture
vertebral column and ribs horizontal Clavicle "V" shape Hip flexion contracture Excessive DF Head cannot stay centered Shld & hips abd/er, knee elbows flexed, Hand to mouth- projection of arm to stationary object no grasp Ballistic mv Motor function goal is to clear airway in prone
skin lesions caused by ________ are warts, herpes simplex, herpes varicella and herpes zoster
viral infections
what do we expect to assess from the eyes in our senses assessment
visual acuity, external and ocular structures, PERRLA (pupils equal, round, reactive to light, and accomidation), assessing distance through snellen, jaeger or rosenbaum tests
explain the inspection technique of a physical assessment
visual exam of the body, including body movement, posture, and smells
what are examples of positive signs of pregnancy
visualization of fetus by ultrasound, auscultation of fetal heart tones, doppler, fetoscope, palpation of fetal movements, observable fetal movements
loss of pigment
vitiligo
calcium
weight bearing activities increase calcium absorption by bones
social communication is
what occurs among individuals who know each other and is informal
Postural Reactions
what types of reactions develop that help to keep the child upright with respect to gravity and protect him in case of a balance Righting reactions, head oriented to space proper alignment protection reactions -reactive and anticipatory and equilibuium reactions-postureal control
reproduction - personal/psychosocial
•Breast self-exam (BSE) monthly at same point in cycle (menopausal women just pick a day of the month, like birthday) - actually more helpful than Clinical breast exam (CBE) because patient knows own breasts, MD examines them once/year •Should include examination of armpits (lymph nodes located there) •Use a thorough pattern of palpation to be sure all areas are checked •Clinical breast exam (CBE) once/year
tissue integrity - family history
•Cancer •Autoimmune disorders, may manifest with symptoms like skin rash or alopecia
tissue integrity - nail palpation
•Capillary refill - discussed during perfusion
tissue integrity - moles
•Changing or irregular mole may be a sign of malignancy (cancer) - changes in color, size, or shape
tissue integrity - present health status
•Chronic illness: liver failure (jaundice), renal failure, autoimmune diseases cause changes to the skin (i.e., pruritus, dryness, skin lesions) •Meds can cause side effects that are manifested in skin, including allergic reactions (i.e., hives, rashes, photosensitivity, acne, thinning of skin, stretch marks) •Occupational exposure to chemicals - can be absorbed through the skin
tissue integrity - inspection skin
•Color - should be consistent as the rest of the body •Moles, Freckles, Birthmark, Striae - all considered normal variations
tissue integrity - nail inspection
•Color - should be pinkish •Cleanliness - should be relatively free of dirt •Markings - should be smooth •Shape - slight rounded is normal •Angle - assess for clubbing
reproduction - pregnancy monitoring
•First & Second Trimester - visits are monthly •Third Trimester (at 28 weeks) - visits are every 2 weeks •Third Trimester (at 36 weeks) - visits are weekly
tissue integrity - hair distribution
•Hair that is dry, easily pluckable can be stress or systemic disease (i.e., protein deficiency, alopecia)
mobility - spine
•Inspect cervical, thoracic, and lumbar spine for alignment and symmetry •Observe range of motion of the lumbar and thoracic spine •Scoliosis - ask patient to touch toes and observe spinal column for straightness
mobility - lower extremities
•Inspect hips for symmetry and height •Inspect knees for symmetry and alignment •Inspect ankles and feet for symmetry and alignment •Observe range of motion of hips, knees, and ankles •Test muscle and joint strength of hips, knees, and ankles
mobility - head
•Inspect musculature of the face for symmetry •Ask patient to open and close mouth, and to smile •Palpate the temporomandibular joint for movement, sounds, and tenderness •Audible sound or palpable snapping or clicking without other symptoms is normal •Observe jaw motion
mobility - neck
•Inspect neck for symmetry and musculature •Palpate the anterior and posterior neck for tenderness •Observe neck range of motion (passive) •Test neck strength
mobility - upper extremities
•Inspect shoulders for symmetry and height •Inspect joints of wrist, fingers, and hands for symmetry and alignment •Palpate muscles and bones for masses and tenderness •Palpate elbow for tenderness •Test muscle and joint strength of shoulder, elbow, wrist and fingers
reproduction - pregnancy examination
•Inspect the abdomen for surface movements and fetal movement •Palpate the abdomen for fetal movement and uterine contraction •Fetal movement should be present at 20 weeks, absent after 22 weeks is abnormal •Fundus •Measure from the top of the symphysis pubis to the top of the fundus •Week 20-36 weeks, fundal height should increase 1 cm per week
reproduction - gynecologic and obstetric history
•Last menstrual Period (LMP) •Nagele's Rule: (LMP - 3 months) + 7 days = helps determine approximate due date •Gravidity (G) = number of pregnancies, including current •Full term births (T) = number of full term births •Preterm births (P) = number of preterm births •Abortions (A) = number of abortions •Living children (L) = number of living children
tissue integrity assessment
•Location - clear anatomical terminology •Size - use a measuring device (i.e. ruler, etc.) •Presence of Tunneling •Drainage - color, consistency, odor, amount •Conditions of wound edges and surrounding tissue •Wound bed
mobility - children and toddlers
•Motor Development Tables - compare data with tables of normal age and sequence of motor development •Measure height and compare values to tables of percentiles for growth •Trendelenburg Sign - test for hip dysplasia •Stand on one leg •Pelvis should NOT tilt downwards on opposite leg •**If tilt is noted = hip dysplasia*
mobility - newborn and infants
•Positioning - undressed and lying supine •Clavicles - palpate for fractures •Stable and smooth clavicles without crepitus •Arms and legs should have equal and spontaneous movement •Arms and legs should be equal in length •Hips •Barlow and Ortlani Maneuver - performed until 3 months •The infant is supine •Flex the infant's knees holding inner thighs with thumbs •Adduct the legs exerting downward pressure •Abduct the legs by moving the knees apart and down toward the table •**Should feel smooth with NO CLICKS •Allis' Sign •Infant is lying supine •Flex the knees with the feet flat on the table and align the femurs •Knees should be the same height
reproduction - general health history
•Present Health Status - current illnesses, medications. Allergies •Past Health History - medical and surgical •Family History •Personal and Psychosocial History •Attitude toward pregnancy •Nutritional history •Tobacco, alcohol, and illicit drug use •Environment
tissue integrity - personal
•Skin care •Sun exposure
reproduction - high risk pregnancies
•Smoking •Sexually transmitted diseases (STDs) •Cancer •Diabetes
reproduction - present health status
•Some meds can cause breast discomfort or discharge •Caffeine-containing foods (chocolate)/ coffee can cause benign breast disease (cysts)
tissue integrity - pressure ulcer stages (4)
•Stage 1 - intact, non-blistered skin with non-blanchable erythema •Stage 2 - a partial thickness that involves the epidermis and/or dermis, but does not extend below the dermis •Stage 3 - full thickness wounds that extend into the subcutaneous tissue but do not extend through the fascia to muscle, bone, or connective tissue •Stage 4 - involves exposure of muscle, bone, or connective tissue •Unstageable - full thickness where the necrotic tissue, or eschar, in the wound bed makes it impossible to assess the depth - deep tissue - area of intact skin that is purple or maroon or a blood filled blister
tissue integrity - palpate skin
•Texture - should be smooth, soft, intact, and even •Temperature - dorsal aspect of the hand, should be warm (hands and feet may be cooler) •Turgor - previously discussed during perfusion •Edema - previously discussed during perfusion •Moisture - dry, minimal perspiration
tissue integrity - skin color
•Vitiligo (Michael Jackson) •Also poor perfusion, interpersonal violence •Assess if explanation matches discoloration (i.e., "fell into a door" but bruises in the shape of an open hand) •Cyanosis/pallor - can indicate poor perfusion (decreased BP) or poor gas exchange (decreased SpO2)
