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NURS 321 Exam 3 Practice Questions and Answers (100% Pass)
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NURS 321 Exam 3 Practice Questions and Answers (100% Pass)
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©PREP4EXAMS@2024/2025 REAL EXAM DUMPS Monday@ August 5@ 2024 6@07 PMNURS 321 Exam 3 Practice Questions and Answers (100% Pass)
Lymph history - ✔️✔️HPI:
- enlarged nodes
- lymphedema
PMH:
- chronic illness/infection/autoimmune dz
- surgery
- allergies
FH:
- cancer, infectious dz, TB, autoimmune dz
PSH:
- travel
- IV drug abuse (IVDA)
- sexual history
PV history - ✔️✔️HPI:
- leg pain, edema
- delayed wound healing
PMH:
,©PREP4EXAMS@2024/2025 REAL EXAM DUMPS Monday@ August 5@ 2024 6@07 PM
- DM, HTN, hyperlipidemia, obesity, renal failure, pulmonary disease, rheumatic
fever
- murmurs
- surgeries
FH:
- risk factors related to CV dz (similar to atherosclerosis)
PSH:
- Diet
- Exercise
- Tobacco, alcohol, drug use
- Psychiatric history (depression, anxiety, stress)
- Stress management
Lymph exam - ✔️✔️Inspect:
- visible nodes
- lymphedema
- erythema
Palpate:
- head, neck, axillary, and LE nodes (normally not palpable)
Palpate lymph nodes for... - ✔️✔️size, consistency, mobility, borders, tenderness,
warmth
*also document location if palpable
,©PREP4EXAMS@2024/2025 REAL EXAM DUMPS Monday@ August 5@ 2024 6@07 PM
Lymphedema grading - ✔️✔️0-3; pitting occurs in EARLIER stages and disappears
in later stages
- 0: latent, swelling not visible, lasts months-years before visible edema develops
- 1: early accumulation of protein-rich fluid that SUBSIDES with limb elevation;
MAY BE PITTING
- 2: tissue FIBROSIS; swelling RARELY subsides with limb elevation; MAY BE
PITTING
- 3: lymphostatic elephantiasis; NO PITTING; skin changes (acanthosis,
thickening, fat deposits, fibrosis, warts)
PV exam - ✔️✔️VS:
- standard VS
- orthostatic HTN
- ankle brachial pressure index
Inspect:
- skin color/texture
- presence of hair
- muscular atrophy
- edema, variscosities
Palpate:
- pulses (carotid, brachial, radial, femoral, popliteal, posterior tibial [ankle],
dorsalis pedis [top of foot])
- warmth
- tenderness
- pitting edema
, ©PREP4EXAMS@2024/2025 REAL EXAM DUMPS Monday@ August 5@ 2024 6@07 PM
Auscultate:
- bruits (carotid, abd aorta, renal, iliac, femoral)
Orthostatic HTN assess - ✔️✔️measure BP/HR in 3 diff positions (lay down, sit
down, stand up) w/ some time btwn
Ankle brachial pressure index - ✔️✔️Compares systolic BP in UE and LE to assess
LE blood flow for patients at risk of PVD
systolic BP leg / systolic BP arm = ?
~1 is normal
less suggests ischemia
Varicose vein assess - ✔️✔️stand up and do toe raises
Pulse grading - ✔️✔️0-4+
0: absent
1+: weak
2+: normal, brisk
3+: increased
4+: bounding
Pitting edema grading - ✔️✔️0-4+
0: absent
1+: 2mm, barely perceptible
2+: 4mm with few second rebound
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