Exam (elaborations)
NR 304 Final Exam Questions And Answers Latest Update 2024/2025
- Course
- NR 304
- Institution
- Chamberlain College Nursing
NR 304 Final Exam Questions And Answers Latest Update 2024/2025
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NR 304 Final Exam Questions And AnswersLatest Update 2024/2025
Health history
a collection of subjective information that provides information about the patient's health status
Steps to setting priorities
1. Assign high priority to First-level priority problems (immediate priorities): Remember the "ABCs plus
V"
2. Next, attend to Second-level priority problems:
Mental status change (ex. confusion, decreased alertnesS) Untreated medical problems requiring
immediate attention (ex. a diabetic who has not had insulin)Acute pain, Acute urinary elimination
problems, Abnormal laboratory values
Risks of infection, safety, or security (for hte patient or for others)
3. Address Third-level priority problems (later priorities):
Health problems that do not fit into the above categories (ex. problems with lack of knowledge, activity,
rest, family coping)
Is pain a normal process of aging?
No, although it is a common experience it is NOT normal
Acute pain responses to the respiratory system
Hypoventilation
Hypoxia
Decreased cough
Atelectasis
Acute pain behaviors include
Guarding
Grimacing
Vocalizations such as moaning
Agitation
Restlessness
,Stillness
Diaphoresis
Change in vital signs
Chronic pain behaviors include
Bracing
Rubbing
Diminished activity
Sighing
Change in appetite
Objective assessment of the skin
Skin color and general pigmentation
Temperature
Moisture
Texture
Thickness
Edema
Mobility and Turgor
Vascularity or bruising
Lesions
When performing a skin assessment what clinical manifestations of dehydration could there be
Mucous membranes are dry, and lips look parched and cracked.
With extreme dryness the skin is fissured, resembling cracks in a dry lake bed.
Danger signs of pigmented lesions
ABCDEF:
Asymmetry (not regularly round or oval, two halves of lesion do not look the same)
Border irregularity (notching, scalloping, ragged edges, poorly defined margins)
Color variation (areas of brown, tan, black, blue, red, white, or combination)
Diameter greater than 6 mm (i.e., the size of a pencil eraser), although early melanomas may be
diagnosed at a smaller size.
Elevation or Evolution
Funny looking (refers to the “ugly duckling” sign, in which the suspicious lesion stands out as looking
different compared with its neighboring nevi)
,Pressure Injuries risk factors
Immobilization / impaired mobility
Thin fragile skin of aging
Decreased sensory perception
Impaired level of consciousness
Moisture from urine or stool incontinence
Excessive Perspiration or wound drainage
Shearing injury
Poor nutrition
Infection
Interventions for pressure ulcers
Turn frequently
Ambulate
Good skin care
Balanced diet with protein, vitamins, minerals
How do you assess jaundice on dark skinned patients?
Sclera of eyes
Junction of hard and soft palate
Palms
urge incontinence
involuntary urine loss from overactive detrusor muscle in bladder
stress incontinence
involuntary urine loss with physical strain, sneezing, or coughing caused by weakness of pelvic floor
What two things determine how complete a patients health history will be?
Time and patient priorities
Purpose of health history
To obtain subjective data from patients to later combine with objective date found during assessment
and make a judgment or diagnosis about the patients health status
Health History Sequence
1. Biographic data
2. Reason for seeking care
, 3. Present health or history of present illness
4. Past history
5. Medication reconciliation
6. Family history
7. Review of systems
8. Functional assessment or activities of daily living (ADLs)
First-level priority problems
emergent, life-threatening, and immediate, such as establishing an airway or supporting breathing
Second-level priority problems
those that are next in urgency requiring your prompt intervention to forestall further deterioration.
(mental status change, acute pain, acute urinary elimination problem, untreated medical problems,
abnormal lab test results
Third-level priority problems
those that are important to the patient's health but can be addressed after more urgent health
problems are addressed. (Knowledge deficit, altered family processes, and low self esteem)
What are the four types of of databases an examiner may use?
Complete
Focused or problem centered
Follow up
Emergency
What screening questionnaire is used to identify excessive or uncontrolled drinking?
CAGE
Have you ever felt you should Cut down on your drinking?
Have people Annoyed you by criticizing your drinking?
Have you ever felt bad or Guilty about your drinking?
Have you ever had a drink first thing in the morning to steady your nerves (Eye-opener)?
levels of consciousness
1. Alert
2. Lethargic
3. Obtunded
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