NUR 355 Final Exam Blueprint Worksheet PDF

NUR 355 – Final Exam Blueprint Worksheet ⮚ Define the following terms: o Strabismus deviation in the parallel axes of the two eyes - cross eyes o Cataracts opaque black areas against the red reflex - cloudy area in the lens of the eyes o Presbyopia dec...

NUR 355 – Final Exam Blueprint Worksheet ⮚ Define the following terms: o Strabismus deviation in the parallel axes of the two eyes - cross eyes o Cataracts opaque black areas against the red reflex - cloudy area in the lens of the eyes o Presbyopia decrease in power of accommodation with aging - hard to see things up close o Nystagmus back and forth oscillation of the eyes - rapid, repeat, uncontrolled movement o Bibasilar pneumonia (PNA) abnormal sounds from the base of the lungs o Bruit sound of blood flowing through a narrowed portion of an artery o Thrill abnormal vibration that is felt on the skin overlying a loud cardiac murmur o Patella kneecap o Tactile Fremitus palpable vibration of the chest wall, transmission of sound vibrations through lung tissue to the chest wall - 99 o Muscular Atrophy loss of muscle o Pleural Friction Rub breath sound heard on lung auscultation o Orthopnea shortness of breath (dyspnea) laying on your back/supine position o Tinnitus perception of sound that does not have an external source o JVD (jugular vein distention) vein that runs down the right side of the neck is swollen o Melena black tarry stool o Lordosis increase in the curve toward the front of your body o Trendelenburg supine position, head down, feet up ⮚ When should a nurse wear gloves? Provide at least one example of when they need to and not. when we’re dealing with fluids  NUR 355 – Final Exam Blueprint Worksheet when they are doing a subjective assessment ⮚ What is the correct order to assess an abdomen? Why is this order important? inspect, auscultate, percussion, palpate - upside down U- right side ⮚ What is the best technique used to assess skin turgor? the elasticity of the skin - pinch skin ⮚ What is a pulse and what does it reflect? Tip: why are some weak, bounding…etc number of times the heart beats in one minute - decreased cardiac output: weak pulse - strong, bounding: exercise ⮚ What is a Snellen chart and what do the results mean? eye chart measures your visual acuity, or sharpness of vision - 20/60 feet - a normal person can read at 60 ft away ⮚ What is an ophthalmologist vs optometrist? ophthalmologist: eye care specialist optometrist: non-medical, regular vision care and primary health care for the eye ⮚ What are the ROM capabilities of the lower extremities? ROM- range of motion forward extension, backward bend knee/ straight knee abduction/adduction external/internal rotation extension of knee/flexion ⮚ Identify when the stethoscope diaphragm vs bell is used. Apply this to each body system and determine if/when each will be utilized when auscultating. bell: low pitch / abnormal sounds - blood vessels ⮚ What is the correct assessment order for all body systems (except abdomen)? inspection, palpation, percussion and auscultation - IPPA ⮚ What is Receptive Aphasia vs Expressive Aphasia? receptive aphasia: wernicke’s language disorder; difficulty understanding spoken or written language - long sentences that don’t make sense - affects language comprehension  NUR 355 – Final Exam Blueprint Worksheet expressive aphasia: broca’s person has trouble expressing themselves through speech or writing - able to comprehend language - speech is halting and fragmented - short phrases - impacts language production and expression ⮚ What are the common body positions? Identify at least one reason a patient would be in that position…For example: What is the most appropriate position for a vaginal examination? Or What is the best position to assist someone that has aspiration precautions? supine laying flat on the back sleeping, after lumbar ulcer injuries puncture, cardiac procedure, abdominal surgery, head-to-toe assessment, vaginal examinations prone laying flat on the spinal surgery eye damage - on abdomen - move secretions pressure injuries(ear) -legs extended - improve gas brachial plexus injury exchange most monitor airway stay - eases the open workload on the heart dorsal recumbent laying flat on back with foley catheter pressure injuries - dorsal: the back knees bent - shoulder - recumbent: laying - heel down - back of the head - bent: knees bent lithotomy laying flat on the back - remove stones with legs flexed at a - childbirth 90-degree angle at the - vaginal exams hip - genitourinary - stirrups used system surgeries sim’s position/ laying on the left side - foley catheter pressure injuries semi-prone - right knee and hip - enema flexed administration - left hip and knee - sleep slightly straight  NUR 355 – Final Exam Blueprint Worksheet lateral to the side of seizure, unconscious - pressure injuries position/recumbent patient - damage brachial - prevent plexes aspiration and help keep the airway open surgery of hip or kidney low fowler’s head of bed: 15-30 - sleeping degree - post op semi fowler’s head of bed: 30-45 - increased degree intracranial pressure - decreases pressure - GI “enteral” feeding - suctioning - critical care fowler’s position 45-60 degree angle eating, drinking Trendelenburg feet elevated, head - central venous lowered catheter line - pelvic surgeries ⮚ What are the “6 cardinal positions of gaze”? What is being assessed? - straight - up - down - right - left - looking diagonally in both directions ⮚ What is Down syndrome (trisomy 21)? genetic disorder caused when abnormal cell division results in extra genetic material from chromosome 21 - mental and physical deformities ⮚ Identify at least 3 methods to assess and monitor trends with regards to pain assessment. Then, identify a patient population that may be appropriate for each pain assessment method. - number rating scale (NRS) - adult  NUR 355 – Final Exam Blueprint Worksheet - verbal scale - visual - kids ⮚ If a patient is experiencing pain in a specific area/body system should you assess that area at the beginning of your assessment? Middle? Last? last ⮚ What is an intercostal space? space between two ribs ⮚ What are the valves within the heart? Where is the best place to auscultate each one? Are you going to use the diaphragm or the bell to auscultate for murmurs? All Patients Take Medicine ⮚ What does a murmur sound like? blowing, whooshing, or rasping ⮚ What is an important hygienic process with regards to equipment use between clients? What is the best product to use in order to complete this process? Should this be also done when sharing equipment amongst colleagues? proper cleaning and disinfection - disinfection solution / wipes ⮚ What are important and respectful steps and interventions leading up to performing a physical examination of a sensitive nature? privacy, introducing yourself, personal space, active listening, explaining process ⮚ What is the nursing process? What is always done FIRST? ADPIE assessment diagnosis planning implementation evaluation ⮚ Compare the tympanic membrane assessment techniques of infant vs adolescent vs adult. What are the ear structures to be mindful of? infant: - pull pinna backward and downward children/adolescents: - tilt their head towards the opposite shoulder - pull pina upwards and backward adults: - head towards the opposite shoulder - pull pinna upwards and backwards ⮚ What intervention will be prompted if you are finding it difficult to palpate a pulse in an upper or lower extremity? Would you need to utilize a special piece of equipment? Doppler ultrasound device ⮚ What is a mental status examination? Are there multiple components to this specialized examination? systematic check of emotional and cognitive functioning  NUR 355 – Final Exam Blueprint Worksheet -ABCT appearance, behavior, and cognition, through processes ⮚ Identify common adventitious lung sounds and their characteristics. Discontinuous Description mechanism example crackles-fine / rales high-pitched, short inhaled air pops open late inspiratory crackles crackling, popping previously deflated in restrictive diseases sounds airways or cause airway - pneumonia, closure heart failure crackles-coarse Loud, low-pitched air collides with pulmonary edema, bubbling sounds , early secretions in large pneumonia, pulmonary respiration, may airways fibrosis decrease with coughing but reappear atelectatic crackles fine crackles that re-expansion of aging adults, bedridden disappear after a few deflated alveoli with individuals breaths secretions pleural friction rub coarse , low pitched , inflamed pleurae rub pleuritis grating sound, heard together due to loss of both during inspiration normal lubricating fluid and expiration continuous wheeze- high pitched high-pitched, musical air squeezed through asthma, chronic (sibilant) squeaking sound, narrow passageways emphysema during expiration wheeze-low-pitched low-pitched, snoring airflow obstruction due bronchitis, airway (sonorous rhonchi) sound, prominent on to narrowed tumors expiration, may clear passageways with coughing stridor high-pitched, crowing upper airway croup, acute epiglottitis sound, louder in the obstruction in the , foreign body neck, heard during larynx or trachea inhalation inspiration ⮚ What is crepitus, and what examination technique do you use to assess it? grating, crunching, popping, or crackling- heard or felt sensation when we move the joint through ROM air, gas, or cartilage fragments move in tissues when they shouldn’t normally be - palpation ⮚ What is edema, and what examination technique do you use to assess it?  NUR 355 – Final Exam Blueprint Worksheet swelling caused by excess fluid trapped in the body tissues - interstitial spaces - eye, bowels, brain, legs, feet, and ankles push your finger over a bony prominence and you let go; it should be pitching edema ⮚ Compare and contrast: Data Validation, Data Clustering, Data Collection, and Data Interpretation ⮚ What is a “Weber’s test” and how is it performed? What about a “Rinne’s test”? Compare and contrast. Weber’s test: vibrating tuning fork is placed on the mid-forehead of the vertex - which ear hears the sound better better? Rinne’s test: air conduction to bone conduction ⮚ What is the best position to help facilitate a patient’s breathing when they have pneumonia affecting both lungs? 45-degree semi-fowler’s position, promotes lung expansion and reduces pressure from the abdomen on the diaphragm - chest wall expansion and drainage of secretions from the lungs ⮚ What are the physical s/s of testicular and breast cancer? How often should this be assessed independently by the client at home? Tip: Compare and contrast a “normal” breast/testicular exam and an “abnormal” breast/testicular exam. normal breast abnormal breast - breasts are smooth without lumps, - lump or thickened are in the breast or thickening or dimpling armpit - no nipple discharge or skin changes - nipple retraction, redness or scaling of the - lymph nodes in armpits are not enlarged nipple - breast skin dimpling or pitting - nipple discharge, especially bloody discharge normal testicular abnormal testicular - testes are smooth without lumps or - lump or swelling in the testicle swelling - dull ache or heaviness in the scrotum - cords are free of lumps or tenderness - breast tenderness or enlargement ⮚ Identify “normal” and “abnormal” results of the following assessments: pulse strength, edema, bowel sounds, and pupils. normal abnormal  NUR 355 – Final Exam Blueprint Worksheet pulse strong, easily palpable weak, thready, bounding pulses edema no edema present pitting edema ( skin se hunde) over a bony prominence bowel sounds active, high-pitched, gurgling absent, hypoactive, or sounds hyperactive bowel sounds pupils equal, round, reactive to light, unequal, irregular shape , and accommodation sluggish or non-reactive pupils ⮚ What is the purpose of completing a physical assessment on your patients/clients? determine the patient’s current health status and identify any deviations from normal, gather objective data, monitor patients' responses to treatments and therapies; and progress over time ⮚ What are “normal” and “abnormal” assessment findings of the carotid artery? normal abnormal pulse is easily palpable, strong, and regular weak, thready or absent pulse no bruits (abnormal vascular sounds) are heard bruits heard over the artery no tenderness or masses present along the artery tenderness, swelling or pulsatile mass along artery unequal pulses ⮚ Generally speaking, what is a reflex, and how is one “elicited”? Are there tools and equipment used? How is it rated and documented? Where on the body would you commonly see this done? Reflex: involuntary and instantaneous movement in response to a specific stimulus - tapping a tendon with a reflex hammer - brushing the sole Graded: 0-4+ scale Commonly tested: knee jerk, ankle jerk, biceps, triceps and plantar reflexes ⮚ Subjective vs Objective assessment and documentation Subjective Objective information based on pt personal experiences, observable and measurable findings obtained feelings, and perceptions through assessment techniques ex. symptoms vital signs, skin color, breath sounds, lab results Recorded using quotations or the patient's word factually without interpretation ⮚ Define GCS (Glasgow Coma Scale) and know how it is scored. neurological scale used to assess and rate the level of consciousness in a person  NUR 355 – Final Exam Blueprint Worksheet - 3(deep coma) to 15(fully awake) Eye Opening: 1= no eye-opening 2= eye opening to pain 3= eye-opening to verbal stimuli 4= eyes open spontaneously Verbal Response 1= no verbal response 2= incomprehensible sounds 3= inappropriate words 4= confused 5=oriented Motor Response 1= no motor response 2= extension to painful stimuli 3= abnormal flexion to painful stimuli 4= flexion/withdrawal from painful stimuli 5= localizes painful stimuli 6= obeys command ⮚ Describe what a “normal” heart sounds like. Identify: S1, S2, S3, S4 ⮚ How is a pulse strength rated and documented? Pulse strength: volume of blood ejected against the arterial wall with each contraction 0- absent 1- diminished or barely palpable 2- normal pulse strength 3-full or bounding pulse 4+- bounding, forceful pulse ⮚ Compare and contrast the sound of cardiac murmurs vs incompetent heart valve. cardiac murmurs incompetent heart valve abnormal swishing or whooshing sound caused by allows the backflow of blood, the murmur is louder turbulent blood flow through the heart and harsher ⮚ What is a Romberg’s test, and what will indicate it is “positive” or “negative”? neurological test that checks and diagnoses disorders of balance and sense of space - positive: inability to maintain an erect posture over 60 seconds with eyes closed ⮚ How do we assess for capillary refill and what is a “normal” result? How is it rated and documented? What are some things that we should do if the cap refill is “abnormal”? 1. apply firm pressure to the nailbed or skin for 5 s 2. release pressure and observe how quickly normal skin color returns  NUR 355 – Final Exam Blueprint Worksheet Normal capillary refill is