NR 302 final review
2 causes of arterial insufficiency - ANS-ischemia, arteriosclerosis or decreased blood flow
a 65 year old man with emphysema and bronchitis has come to the clinic for a follow up
appointment, on assessment of his skin , the nurse might expect to assess the following -
ANS-clubbing of the nail which may indicated COPD, and lack of oxygen over time
a 67 year old patient states he recently began to have pain in his left calf when climbing 10
stairs to his apartment, the pain is relieved by sitting for about 2 minutes, then he is able to
resume his activities, the patient is most likely experiencing - ANS-arterial obstruction or
claudication
a mother is at the clinic with her 2 year old son, "he wont go to sleep at night and during the day
he has several fits" I get so upset when this happens, the nurses best verbal response would be
- ANS-to clarify and get more information, fits?, tell me what you mean by this
a mother presents with her son, who has been in a new day care facility, on examination the
nurse asses moist, think vesicles with an erythematous base around the nose and mouth, the
nurse suspects - ANS-impetigo
a nurse is assessing a patient admitted with congestive heart failure (CHF) for edema, the nurse
assesses this in dependent parts of the body, when applying pressure there is a dent in the skin
that last very long time, the nurse would document this as - ANS-4+ pitting edema for 8 mm
indentations
a nurse is performing a lung assessment on a patient diagnosed with RLL pneumonia, the
patient is asked to say "eee" and through the stethoscope the nurse hears an "aaa" sound over
the RLL, what term would document the finding - ANS-egophony
a patient with a long history of COPD is being assessed, the nurse would be likely to inspect -
ANS-hypertrophied neck muscles, anterior/posterior-to transverse diameter of 1:1 and tripod
positioning
a patients reason for seeking care is shortness of breath, when obtaining a health history, which
of these questions by the nurse would obtain the most helpful information - ANS-will you please
describe the activities that cause you to be short of breath
accommodation - ANS-distance to near where pupils constrict, and eyes converge, part of
PURRLA test
, after completing an initial assessment on a pt, the nurse charts, vital signs as temp of 100.1
oral, apical HR 98 irregular, RR 24 shallow, B/P 128/90, pulse ox of 90% on RA, what are you
worried about - ANS-oxygenation, infection, activity intolerance, capillary refill greater than 3
seconds
an adult patient with a history of allergies comes to the clinic with complaints of wheezing and
dyspnea, the assessment reveals nasal flaring, use of accessory muscles and tachypnea, the
description is consistent with - ANS-asthma
an example of objective data obtained during the physical assessment includes - ANS-audible
and auscultated inspiratory wheeze, 2x2 cm stage 1 pressure ulcer on right ankle, crackles that
clear with cough
apical impulse - ANS-intercostal space, palpate for impulse, auscultate for pulse, turn obese
patients to the left side
arterial ulcer - ANS-dry, coolness, pallor, elevational pallor, dependent rubor, diminished pulses,
systolic bruits, signs of malnutrition, think, shiny skin, thick ridged nails, atrophy of muscles, and
distal gangrene
atelectasis - ANS-collapse of the alveoli
audible vs. ausculated - ANS-auscultated is hearing through stethoscope while audible is heard
within the room
BMI normal range - ANS-18.5-24.9
CHF or Congestive Heart Failure - ANS-weakening of the heart muscle
components of a health history - ANS-biographical data, review of systems, functional
assessment, activities of daily living
conductive vs. sensorineural hearing loss - ANS-conductive is due to obstruction and
sensorineural is due to neural changes
conjunctiva - ANS-bottom eye lid where eye drops are put in, on black skin patient check for
discoloration indicating certain diseases
cranial nerve I - ANS-olfactory for smell, nasal patency test
cranial nerve II - ANS-optic for sight, snellen chart, visual fields
cranial nerve III - ANS-oculomotor, PERRLA test
