NUR 216 Final Exam Study Guide Questions.docx

Final Exam Study Guide -- NUR 216 [General/Miscellaneous/Assessment Techniques] - What is subjective data? What are some examples? - What is objective data? What are some examples? - Physical assessment techniques & tools - Which sounds do we use the bell of the stethoscope for? The...

Final Exam Study Guide -- NUR 216 [General/Miscellaneous/Assessment Techniques] - What is subjective data? What are some examples? - What is objective data? What are some examples? - Physical assessment techniques & tools - Which sounds do we use the bell of the stethoscope for? The diaphragm? - Which do we use for breath, bowel, & heart sounds (S1/S2)? - Which do we use for low-pitched sounds and vascular sounds? What are the vascular sounds that we assess for? - What equipment needed for head-to-toe assessment? - What is the purpose or goal of organizing the physical assessment into a "head-to-toe" systematic approach? - What general order of body systems should we follow when organizing the head-to-toe assessment? What is the first component of our physical assessment (before we start with specific body systems)? - What kind of therapeutic communication techniques should we utilize? [Pain] - When/how are the OLDCARTS & PQRST used and what factors do they assess? - What parts of the health history do they NOT assess? - What is the "gold standard" for how we should assess pain? - Why might a patient be unable to self-report? If a patient is unable to self-report (e.g., has cognitive impairment), how should we assess for pain instead? - What symptoms or findings may be caused by acute pain? [General Survey, Vitals, & Nutritional Assessment] - General Survey - What is the purpose of the general survey? - Components - Which component includes body structure and appearance of stated age? - Which component includes assessment of body odor? - Which component includes whether the patient is sitting up straight or hunched over (and what is this called)? - Vital Signs - What is a normal heart rate? - What is a low heart rate called? - What is a high heart rate called? - What is a normal blood pressure (below what)? - What is low blood pressure called? - Where should you avoid placing the blood pressure cuff? - What is a normal oxygen saturation? - What is a normal respiratory rate? - What is a low respiratory rate called? - What is a high respiratory rate called? - What is a normal temperature (range -- depending on route)? - Nutrition - What is a normal BMI? - What BMI is considered underweight? - What BMI is considered overweight? - What BMI is considered obese? - What information is included in a nutritional assessment? [Skin/Hair/Nails] - What are the functions of the skin? - What are fluid-filled lesions \< 1 cm (small blisters) called? - What kind of skin lesion is often caused by a pressure injury? - What is the ABCDE mnemonic for suspicious nevi? What are nevi? [Head, Eyes, Ears, Neck, & Throat] - Which two techniques can be used to assess the facial sinuses? Which involves tapping? - Which assessment techniques are used to assess the external ears (2)? - What are normal findings of the head/skull? - What are normal findings when assessing visual acuity? - What structures on the face/head should be aligned? - Skull normocephalic, symmetrical, nontender - Visual acuity 20/20 in both eyes [Respiratory] - Inspection - What are signs of acute respiratory distress? - Which findings may develop as a result of chronic pulmonary disease (COPD)? - Palpation: Which findings are expected when assessing tactile fremitus? - Breath sounds - What do crackles sound like? - What does rhonchi sound like? - What does wheezing sound like? What diagnoses/diseases cause wheezing? - Education/health promotion for COPD patients - What should individuals with COPD do to promote pulmonary health and prevent complications? What should be avoided or limited as much as possible? [Cardiovascular] - What is the sequence of assessment? - What should a person's total cholesterol level be (below what)? - Anatomy & landmarks - Where is the apical pulse? - Which heart chambers are separated by the mitral valve? - Where is Erb's point? - Where is the tricuspid valve/landmark? - Where is the aortic valve/landmark? - Where is the pulmonic valve/landmark? - Assessing peripheral pulses - Normal findings: What's a normal pulse amplitude? What's a normal rhythm? - What does a pulse amplitude of 0 mean? +1? +3 or +4? - Pulse sites: - Carotid: Where is this? How is it assessed? What are we assessing for when we auscultate and which side of the stethoscope is used? - Upper extremities: Where is the radial pulse site? Where is the brachial pulse site? - Lower extremities: Which pulse sites are located on the lower extremities? - If a pulse is irregular, what should you do? - If you're unable to palpate a peripheral pulse, what should you do? - Which pulse sites may be palpated bilaterally at the same time? - Cardiovascular conditions - What symptoms may be seen in acute left-sided heart failure? - What condition would cause foot wounds and leg/foot pain when legs are elevated? [Neurological & Musculoskeletal] - What does the mnemonic F.A.S.T stand for? - What is each cranial nerve responsible for and how are they tested? (name & number) - What does PERRLA stand for? What equipment is necessary to assess for this? Does it indicate visual acuity? - Vision assessment tools - Which chart do we use to assess visual acuity? - What do we use to assess for color blindness? - Mental status - What is the lowest level of consciousness that is possible while someone is alive? What would you expect in terms of responsiveness at this level of consciousness? - What four things should a person be "oriented to"? - Deep tendon reflexes - When assessing the Achilles reflex, what movement/response is expected? - Range of motion movements - What is adduction? - What is abduction? - What is flexion? - What is extension? - Spinal deformities - What is lordosis? - What is kyphosis? - What is scoliosis? [Abdomen & Rectum/Anus] - General - What should we ask the client to do before beginning the assessment? - What is the sequence of assessment? - Inspection - What is jaundice? What causes it? - What are striae? Is this concerning? - Auscultation - Bowel sounds - How long should you listen for to confirm the absence of bowel sounds? - How many bowel sounds per minute should be heard? - Loud, frequent, high-pitched sounds should be documented as what? - Slow, decreased sounds should be documented as what? - Which side of the stethoscope should be used to auscultate abdominal arteries? - Percussion (indirect) - What should we hear upon percussion? - Percussion of the costovertebral angle (CVA) assesses which organ? - Palpation - If a patient reports abdominal pain, when should you assess the painful area? - If you palpate a mass in the 8^th^ region of the abdomen, what does this indicate? - Anus: what are swollen veins that may cause bright red blood in stool, itching, and/or pain? Can these be visible upon inspection? [Breast & Lymphatic] - Self-breast exams - How often and when should these be done? - How should the patient be positioned? - How should you instruct the patient to perform exams? What should be assessed in addition to the breast tissue on each side? - Lymphatic - What findings are normal when assessing lymph nodes? - What findings are abnormal? [Older Adult] - What accommodations may the older adult need for the health history interview and assessment? - - Percussion of costovertebral angle (CVA) - Indirect percussion on back to assess for renal inflammation - What findings are age-related and expected? [Tips] - Remember the nursing process...always begin with assessment - Remember the sequence of assessment when thinking about what to do "first" or "next" - For the cranial nerves, you are responsible for knowing BOTH the name and number as exam questions may contain either the name or number but may not give you both - Prioritizing: think "ABCs" - Increased respiratory rate, hypoxia, breathing problem, respiratory distress, or airway obstruction should be highest priority, followed by circulation concerns - E.g., respiratory rate of 26 should be prioritized over BP 130/84, even though the BP is technically high - Read the question very thoroughly...consider whether it's asking about OBJECTIVE vs. SUBJECTIVE information (the question may not be a "prioritization" question even if it seems that way at first glance)