Nurs 252 Final Review Questions and Complete Solutions
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Course
NUR 252
Institution
NUR 252
Priority levels 1. Immediate (emergency, life threatening) 2. Second level (urgent, must be addressed to prevent further deterioration) 3. Third level (important to patient health) 4. Collaborative problems ( interprofessional team, ex. substance abuse)
Arranging the physical setting - Minimize in...
Nurs 252 Final Review Questions and
Complete Solutions
Priority levels ✅1. Immediate (emergency, life threatening)
2. Second level (urgent, must be addressed to prevent further deterioration)
3. Third level (important to patient health)
4. Collaborative problems ( interprofessional team, ex. substance abuse)
Arranging the physical setting ✅- Minimize interruptions and establish rapport
-Leave enough distance, and allow for personal space
-Equal seating
Empathy ✅-Recognition and acceptance of patient's feelings
Barriers to professional therapeutic communication ✅-Failing to listen
-Giving personal opinions, approving or disapproving statements
-Changing the subject
-False reassurance
-Interrupting
-Overusing professional jargon
-Talking too much
-"why" questions
General Survey ✅-Age
-Level of alertness
-Body size and shape
-Non-verbal communication
-Symmetrical comparison
Palpation ✅Touch to assess
-Temperature
-Moisture
-Texture
,-Vibration
-Pulsation
-Rigidity
-Crepitus
-Presence of lumps or masses
-Presence of tenderness or pain
Finger pads- palpation regions ✅-Used to assess texture, moisture, and contour
Fingertips/pads (palpation) ✅-Used to assess pulsatility, fluid content of tissues,
elasticity and turgor, and vascularity
Dorsum of hand (palpation) ✅-Used to assess temperature
Ulnar surface of hand (palpation) ✅-Used to assess temperature and vibration
Light palpation ✅- Communicate for patient comfort, use warm hands and go from non
tender areas to tender areas
-Use Intermittent circular motions with Dominant hand
-Finger pads sense movement of patient's skin and tissue
Deep palpation ✅-Risk of injuring patient, up to discretion of nurse within their scope of
practice
-3-4 cm below skin surface
-Extended fingers of non dominant hand over dominant hand for extra pressure
Percussion ✅-Tapping on body surfaces to create sound
-Helps determine location, size and density of organs
-Detects abnormal mass
-Elicits pain on inflamed area
-Deep tendon reflex
Direct percussion ✅-Tap directly on skin
-Maxillary sinuses
Indirect percussion ✅-Tap middle finger of dominant hand over middle finger of non-
dominant hand placed on a body surface
-Tap twice only, using a quick and forceful wrist action
,-Use the diaphragm and bell
-Warm the stethoscope and sanitize
-Hair and friction can produce artifact sounds
-Do not auscultate through clothes
Diaphragm of stethoscope ✅-Flat endpiece of the stethoscope used for hearing
relatively high-pitched heart sounds
-Lung and Heart sounds
Bell of stethoscope ✅-Cup-shaped endpiece used for soft, low-pitched heart sounds
-Heart murmurs
Infants developmental considerations for assessment ✅-Trust the parent
-Prefer warmth
-Perform least distressing assessments first
-Lung, heart and abdominal sounds first if sleeping
Toddlers developmental considerations for assessment ✅-Can have parental
assistance with positioning
-Least distressing assessments first
-Use games/toys
-Praise cooperative children
Preschool developmental considerations for assessment ✅-They have initiative
-Prefer a parental presence
-Can be cooperative, have increasing communication skills
-Still need games/toys
-Least distressing assessments first
School age children developmental considerations of assessment ✅-Industry
-Seek approval, feelings of accomplishment
-Can have small talk about interests
-Perform a head to toe assessment
Adolescents developmental considerations for assessment ✅- Struggle with self-
identity
-Strong awareness of body image
-Educate for self-care
-head to toe assessment
Older adult developmental considerations for assessment ✅-Seated or supine
-Slower pace of examination
-Discriminate between sensory loss and confusion
-Head to toe examination
, Skin function ✅-Protection
-Barrier for penetration
-Perception
-Thermoregulation
-Identification (self-image
-Communication (blushing, blanching)
-Wound repair
-Absorption and secretion
-Vitamin D production
Skin layers ✅1. Epidermis
2. Dermis
3. Hypodermis/subcutaneous layer-has adipose tissue, energy stores, cushioning,
insulation for temp control
Skin colour and tone ✅1. Melanin-brown pigmentation
2. Carotene-yellow/orange
3. Vascular bed- red/purple
-Varies with genetics and health state (edema, fever)
Glands in the skin ✅-Sebaceous glands (open into hair follicles)
-Sweat glands (thermoregulation)
-Eccrine and apocrine glands
Hair ✅-Made of keratin
-Cyclical growth, active and resting phases
-Vellus hair (fine, covers most of the body)
-Terminal hair (dark, thick)
Nail plate, folds and cuticle ✅-Made of keratin
-Pink colour indicates highly vascular epithelial cells
-Lunula is the white semilunar area at proximal end of nail
-Nail fold overlaps posterior and lateral borders
-The cuticle protects nail matrix
Puritis ✅-Intense itching
Things to look for in a skin assessment ✅-Previous history of skin disease
-Changes in pigmentation
-Changes in mole (ABCDE)
-Excessive dryness or moisture
-Puritis
-Excessive bruising
Things to look for in a hair and nails assessment ✅-Hair loss
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