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NURS6700 Exam II Study Guide with Complete Solutions

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EMILLYCHARLOTTE 2024/2025 ACADEMIC YAER ©2024 EMILLYCHARLOTTE. ALL RIGHTS RESERVED FIRST PUBLISH SEPTEMBER 2024 Page 3/20 Abdominal Assessment - Answer-Inspection Auscultation Percussion Palpation Auscultation (back) - Answer-Always compare for symmetry! Auscultation (front) - Answer-Alway...

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EMILLYCHARLOTTE 2024/2025 ACADEMIC YAER ©2024 EMILLYCHARLOTTE. ALL RIGHTS RESERVED
FIRST PUBLISH SEPTEMBER 2024




NURS6700 Exam II Study Guide with
Complete Solutions

The Nursing Process - Answer✔✔-AD-O-PIE




Assessment


Diagnosis


Outcomes/Planning


Intervention


Evaluation


Assessment - Answer✔✔-Gathering subjective and objective data


Diagnosis - Answer✔✔-Must be NANDA approved [only nursing diagnoses, not medical]


Outcomes/Planning - Answer✔✔-Goals must be specific to patient and have a time attached to them


Intervention - Answer✔✔-What will you/the PT do to achieve the goals set?


Evaluation - Answer✔✔-Answers the questions, did you meet your goal?


The 3 Part Nursing Diagnosis - Answer✔✔-1. Review NANDA approved list and identify proper diagnosis


2. Identify cause of problem [diagnosis is NOT the cause]



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3. Provide evidence to support nursing diagnosis


Nursing Diagnosis Facts - Answer✔✔-- Focused on the scope of nursing practice


- Errors can occur from inadequate assessment


- Must contain all three parts to be complete


4 Quadrants of the abdomen - Answer✔✔-RUQ, LUQ, LLQ, RLQ


When listening to the abdomen you should... - Answer✔✔-hear tympany, except when over a muscle,

organ, or mass in which case you will hear dull sounds.


Location of organs in abdomen - Answer✔✔-


Liver span - Answer✔✔-Mapping edge of liver using percussion. Do this to determine length and width

(Normal is 6-12cm)


Costo-vertebral Angle - Answer✔✔-Area of back where kidneys are located. Assess this location for

tenderness or inflammation in relation to kidneys.


Flank Area - Answer✔✔-One side of the body (either L or R), between the abdomen and back. [if left

flank pain is present, this is a sign of kidney failure]


Ascites - Answer✔✔-Excess fluid build up in parietal space of abdomen


Abdominal Aortic Aneurysm - Answer✔✔-Enlargement of abdominal aorta [when larger than 3cm or

more than 50% the size of normal]


Respiratory System - Answer✔✔-




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FIRST PUBLISH SEPTEMBER 2024


Abdominal Assessment - Answer✔✔-Inspection


Auscultation


Percussion


Palpation


Auscultation (back) - Answer✔✔-Always compare for symmetry!


Auscultation (front) - Answer✔✔-Always compare for symmetry!


Normal vs. Adventitious Lung Sounds - Answer✔✔-In a normal air-filled lung, vesicular sounds are heard

over most of the lung fields, bronchovesicular sounds are heard between the 1st and 2nd interspaces on

the anterior chest, bronchial sounds are heard over the body of the sternum, and tracheal sounds are

heard over the trachea.


Wheezing is sometimes called - Answer✔✔-Rhonchi


Crackles are sometimes called - Answer✔✔-Rales


Normal vs. Adventitious Percussion - Answer✔✔-Ex. Resonance is heard in healthy lung tissue, while

hyper-resonance is usually heard in COPD patients


Pleural Friction Rub - Answer✔✔-Dry rubbing or grating sound. Usually caused by inflammation in the

pleural spaces.


Tactile Fremitus - Answer✔✔-Using palpation, have patient say "99" and feel vibration in chest wall.

Compare L and R sides.




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