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83 Cards in this Set
- Front
- Back
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The nurse is assessing a postoperative patient for signs of hemorrhage. Which adaptation is most indicative of shock: hyperemia, hypotension, irregular pulse or slow respirations?
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Hypotension
Rationale: The circulating blood volume is reduced by 25-35% during the compensatory stage of shock and 35-50% during the proressive stage of shock as the peripheral vessels constrict to increase blood flow to vital organs. This causes hypotension |
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The nurse is monitoring the vital signs of a group of patients. The nurse must remember that body temp usually is at its highest at: 12 am-2am, 6 am - 8 am, 4 pm - 6 pm, or 8 pm - 10 pm?
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8 p.m. - 10 p.m.
Rationale: Highest temp usually occurs between 8 p.m.-midnight. |
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When assessing for borborygmi, which physical examination method should the nurse use: auscultation, percussion, inspection or palpation?
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Auscultation
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The nurse plants to take a patient's radial pulse. Which method should be used by the nurse: palpation, inspection, percussion, or auscultation?
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Palpation
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Which nursing action is common to all instruments when taking a temperature?
1) Identify that the reading is below 96 before insertion 2) Wash with cool soap and water after use 3) Place a disposable sheath over the probe 4) Ensure that the instrument is clean |
Ensure the instrument is clean
Rationale: this is a medical asepsis practice. |
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The nurse concludes that a patient is experiencing hyperthermia. Which assessment precipitated this conclusion?
1) mental confusion 2) increased appetite 3) decreased heart rate 4) rectal temperature of 101 |
Rectal temperature of 101
Rationale: A rectal temp of 101 or oral temp of 100 is a common human response that indicates hyperthermia |
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The nurse in the ER is engaging in an initial assessment of a patient. Which assessment takes priority?
1) Blood pressure 2) Airway clearance 3) Breathing pattern 4) Circulatory Status |
Airway Clearance
Rationale: PT assessment must be conducted in order of priority of need. A clear airway is essential for life. ABCV's of assessment. |
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The nurse is obtaining a PT's BP. Which info is most important for the nurse to document?
1) Staff member who took BP 2) Patients tolerance to having BP taken 3) Position of the PT if not sitting 4) difference between the palpated and auscultated systolic readings |
Position of the patient, if not sitting
Rationale: The PT's position when the BP is taken may influence results. Generally, systolic and diastolic readings are lower in the horizontal than in the sitting position. |
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The nurse understands that body heat production is increased by?
1) vasodilation 2) evaporation 3) shivering 4) radiation |
Shivering
Rationale: Shivering generates heat by causing muscle contraction, which increases the metabolic rate by 100-200% |
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A patient has a serious vitamin K deficiency. For which adaptation should the nurse assess this patient?
1) skin lesions 2) bleeding gums 3) night blindness 4) muscle weakness |
Bleeding gums
Rationale: A disruption in the clotting mechanism of the body can result in bleeding. Vitamin K plays an essential role in the production of clotting factors |
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At what time of the day do people generally have the lowest body temperature?
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Between 4 am - 6 am
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The nurse is interviewing a newly admitted patient. Which PT statement indicates the onset of fever? "I feel..."
1) Cold." 2) Warm." 3) Sweaty." 4) Thirsty." |
Cold
Rationale: Feeling cold occurs during the onset (chill) stage of fever because of vasoconstriction, cool skin and shivering. |
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A PT has a temp of 102 and complains of feeling thirsty. Which additional adaptation should the nurse expect during the febrile stage of a fever?
1) Restlessness with confusion 2) Decreased respiratory rate 3) Profuse perspiration 4) Pale, cold skin |
Restlessness with confusion
Rationale: may indicate the beginning of delirium associated with high fevers. Delirium is associated with the febrile (fever, flush) stage of a fever. |
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The nurse must take a patient's rectal temperature. The nurse should:
1) take the temp for 5 minutes 2) wear gloves throughout the procedure 3) place the patient in the right lateral position 4) insert the thermometer two inches into the rectum |
Wear gloves throughout the procedure
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What is the term for blue-gray coloration of the skin?
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Cyanosis
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What is the term for tiny, pinpoint red or reddish-purple spots?
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Petechiae
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What are Mongolian spots?
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benign, blue-black birthmarks due to pigmented cells in the deeper areas of skin. Seen in African American, Hispanic, Native American and Asian babies.
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What factors influence skin texture?
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Exposure
Age Hyperthryoidism or other endocrine disorders Impaired Circulation |
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What is the term for breath sounds that are medium-pitched with an equal inspiratory and expiratory phase?
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Bronchovesicular breath sounds
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What is the term for breath sounds that are high pitched, loud and tubular? Expiration is longer than inspiration.
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Bronchial breath sounds
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What is the term for soft, low pitched, breezy sounds with a lengthy inspiratory phase and a short expiratory phase?
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Vesicular breath sounds
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Where would you find/ausculate the aortic valve?
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2nd Intercostal Space Right Sternal Border
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Where would you find/ausculate the pulmonic valve?
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2nd Intercostal Space Left Sternal Border
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Where would you find/ausculate the tricuspid valve?
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4th ICS left sternal border
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Where would you find/ausculate the mitral valve?
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5th ICS Mid-Clavicular line
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The nurse auscultates the patients bowels and notes bowel sounds of 15 per minute. What term would best describe this?
1) Normal bowel sounds 2) Absent bowel sounds 3) Hypoactive bowel sounds 4) Hyperactive bowel sounds |
Normal bowel sounds
Rationale: Normal bowel sounds occur 5-30 times per minute |
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What is the correct order for performing abdominal assessment techniques?
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Inspection
Auscultation Percussion Palpation |
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A nurse is checking the vital signs of a 92-year old client. The client's radial pulse has an irregular beat about every 5th or 6th beat. The rate is 92/min. The client is asymptomatic. The nurse should do which of the following?
1) Report findings to the provider 2) Place the client on telemetry 3) Obtain an electrocardiogram 4) Check an apical pulse for 60 seconds and note any pulse deficits |
Check an apical pulse for 60 seconds and note any pulse deficits
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A nurse is checking the vital signs of a newly admitted PT who has a fractured femur. The PT's BP is 140/94. The client denies any history of HTN. The nurse should do which of the following?
1) Ask the client if she is having pain. 2) Report the elevated BP to the provider 3) Return in 30 minutes to recheck the BP 4) Check orthostatic BP |
Ask the client if she is having pain
Rationale: Her BP may be elevated due to pain. |
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A client asks what her Snellen eye test results mean. Her acuity for both eyes together is 20/30. What does this actually mean?
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She sees at 20 ft. what the normal-sighted person sees at 30 ft.
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What are the four techniques used in physical assessment?
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Inspection
Palpation Auscultation Percussion |
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What are signs of respiratory distress that you might observe in a patient?
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SOB
restlessness decreased mental alertness cyanosis pallor nasal flaring orthopnea intercostal retractions use of accessory muscles increased Heart rate |
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Where would you locate Erb's point?
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3rd ICS left sternal border
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What is the term for obstructed peripheral blood flow that is heard as a blowing or swishing sound with the bell of a stethoscope?
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Bruits
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What is erythema an indication of?
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Inflammation
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Where would you locate the posterior tibial pulse?
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Behind and below the medial malleolus of the ankles
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What kind of lesion would a blister be considered?
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A vesicle
Rationale: it is serious fluid-filled and less than 1 cm |
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When assessing a client's skin temperature, the nurse should use which part of the hand?
1) fingertips 2) dorsal surface 3) palmar surface 4) base of the hand |
Dorsal surface
Rationale: the dorsal surface is the most sensitive to temp changes. |
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What does a neurological screening examination include?
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Mental status examination
Assessment of cranial nerves Motor function to test cerebellar function Sensory function Reflexes |
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Define Inspection
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The use of sight to gather data
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Define palpation
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The use of touch to gather data
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Define auscultation
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The use of hearing to gather data
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Define percussion
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The use of tapping to produce vibrations to gather data
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What are the components of a general survey?
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Appearance and Behavior
Body Type and Posutre Speech Dress, Grooming and Hygiene Mental State Vital Signs Height and Weight |
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How would you scale edema that creates a depression of up to 4mm in depth and that disappears in about 10-15 second?
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+2 edema
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What are the warning signs of malignant lesions?
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A - Asymmetry
B - Border irregularity C - Color variation D - Diameter greater than 0.5 cm E - Elevation above the skin surface |
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What is another term for head lice infestation?
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Pediculosis
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What is PMI and where would you find it?
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Point of Maximal Impulse located at the 5th IC Mid-Clavicular line.
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Define thrill.
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Palpable vibration or pulsation palpated in any area except the PMI. It is associated with abnormal blood flow and usually has an accompanying murmur.
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Where would you find S1?
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Loudest over the mitral and tricuspid areas. It marks the beginning of systole.
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Where would you best hear S2?
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Loudest at the aortic and pulmonic areas
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What does orientation refer to?
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The client's awareness of time, place and person.
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What are the normal ranges for body temperature?
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Oral: 96.8-100.4
Rectal: 98.0 - 101.6 Axillary: 95.8 - 99.4 |
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In what scenarios would you hear hyperresonance in the lungs?
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If there is increased air in lung of pleural space
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What type of breath sounds would you hear in the periphery of the lungs?
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Vesicular
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What adventitious breath sound can usually be cleared by coughing?
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Rhonchi
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What causes wheezes
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Constriction of the airway with resultant blockage of air flow
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Define pleural friction rub
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Low pitched grating and rubbing that is heard equally on inspiration and expiration caused by inflammation of the pleura
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What are the characteristics of heart sounds?
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Frequency
Timing Intensity Duration |
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What heart sound is heard loudest at the apex?
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S1
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What heart sound is heard loudest at the base?
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S2
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How would you encourage relaxation before palpating?
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Palpate tender areas last
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What part of the stethoscope do you use for low pitched sounds?
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The bell
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What part of the stethoscope do you use for high pitched sounds?
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The diaphragm
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What are the two methods used for general survey/physical assessment?
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Head to toe
Body Systems method |
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What type of lesion is nonpalpable, less than 1 cm, flat and colored.
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Macule
Ex. freckle, petechiae, birthmark, Mongolian spots |
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What type of lesion is palpable, less than 1 cm, elevated and raised but superficial
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Papule
Ex. mole, psoriasis |
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What type of lesion is palpable, fluid-filled and encapsulated and is less than 2 cm.
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Cyst
(If not fluid-filled it is called a nodule) |
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Define wheal.
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Elevated, superficial skin lesion with localized edema.
Ex. insect bites, hives |
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Describe normal nail beds.
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Level
Firm Similar to the color of the skin Convex Nail plate angle of about 160 degrees. |
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What types of things would you observe when assessing a lesion?
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Size
Shape and Pattern Color Distribution Texture Exudate Tenderness or Pain Surface Relationship |
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Pallor, Cyanosis, Restlessness, apprehension, confusion, dizziness, fatigue, decreased LOC, tachycardia, tachypnea and changes in blood pressure are all signs of what?
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Hypoxia
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What are the best indicators of hypoxia?
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the tongue and oral mucosa
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What causes clubbing of the fingers?
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Chronic hypoxia
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What measurement is an important indicator of overall cardiovascular health?
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Blood Pressure
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Define Blood Pressure.
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the pressure of the blood as it is forced against arterial walls during cardiac contraction
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What is the term for excessive facial or trunk hair which may be due to endocrine disorders or steroid use
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Hirsutism
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Define alopecia
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Hair loss
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The nurse in the clinic must obtain the vital signs of each patient before each patient is assessed by the practitioner. The nurse should obtain a temp via the rectal route for a patient:
1) who is a mouth breather 2) With a history of vomiting 3) With an intelligence of a 7-yr old child 4) Who cannot tolerate a semi-Fowlers position |
Who is a mouth breather
Rationale: Mouth breathing allows environmental air to enter the mouth which results in an inaccurately low reading. To take an oral temp the instrument must remain under the tongue of a closed mouth until the reading is obtained. |
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The nurse is planning care for a PT who has an intolerance to activity. What is the first assessment that should be made by the nurse?
1) influence on other family members 2) impact on functional health patterns 3) pattern of vital signs 4) range of motion |
Pattern of vital signs
Rationale: obtaining the vital signs will provide valuable info relating to the inability to maintain adequate oxygenation which is related to activity intolerance |
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The nurse is monitoring the status of a postoperative PT. The vital sign that changes first indicating that a postoperative PT has internal bleeding is the:
1) body temperature 2) blood pressure 3) pulse pressure 3) heart rate |
Heart rate
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The nurse in the ER is caring for a patient who has been diagnosed with hyperthermia. The presence of which factor in the PT's history may have precipitated this condition?
1) heat stroke 2) inability to sweat 3) excessive exercise 4) high alcohol intake |
Alcohol intake
Rationale: Excessive alcohol intake interferes with thermoregulation by providing false sense of warmth, inhibiting shivering and causing vasodilation which promotes heat loss. |
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A PT has lost approx. 2 units of blood during a vaginal delivery. For which response to this blood loss should the nurse assess the patient?
1) rapid, shallow breathing 2) increased urinary output 3) hypertension 4) bradypnea |
Rapid, shallow breathing
Rationale: With a decrease in circulating red blood cells, the respiratory rate will increase to meet oxygen needs |
