Cnur 203: Midterm #1

A patientcomes to the hospital clinic and reports that he has been vomiting and haddiarrhea for 3 days. Whichlaboratory value/s would a nurse expect?

a.hyponatremia

b.hypernatremia

c. hypokalemia

d.hyperkalemia

A patientwith hypokalemia from diarrhea will have which of the following signs/symptoms?

a.fatigue, tetany, paresthesias

b.extreme thirst, restlessness, peripheral edema

c. Muscleweakness, irregular heart rate

d.confusion, decreased BP, tachycardia

Gravidity

Term

Preterm

Abortions

PQRSTU

You arejust starting an admission history on a patient who was in a car accident andanother nurse else is taking vital signs. The patient is complaining ofabdominal pain rated 9/10. The vital signs are: BP 84/50, P 112, RR 26, T 37.1oC. What is the priority nursing intervention?

a. Obtain an order for an analgesic

b.Perform a focused abdominal assessment

c.Complete the head-to-toe assessment as planned

d.Recheck the vital signs

Daily servings of Fruits and vegetables:

Daily servings of Grains:

Daily servings of meat and alt.:

Daily servings of milk and alt.:

Daily servings of oils and fats:

Range for normal BMI

Overweight BMI

Obesity BMI

Extreme obesity BMI

Underweight BMI

Normal range for adult body temp

regular pulse rate

Regular resp rate <65

Regular resp rate>65

Regular BP range

Febrile

Afebrile

0/4 force of pulse

1+/4 force of pulse

2+/4 force of pulse

3+/4 force of pulse

4+/4 force of pulse

What blood test would you order to check for fever?

Why do we use the radial pulse?

When would you use the temporal pulse?

When would you use the carotid pulse?

When would you use the apical pulse?

When would you use the brachial pulse site?

When would you use the femoral pulse site?

When would you use the popliteal pulse site?

When would you use the posterior tibial pulse site?

When would you use the dorsalis pedis pulse site?

Symptoms of bradycardia and what to do:

Symptoms of tachycardia and what to do:

Normal adult resp rate

Bradypnea

Tachypnea

Orthopnea

Dyspnea

Normal oxygen saturation for adults

What is a life threatening % for oxygen saturation?

Symptoms of bradypnea and what to do

Symptoms of tachypnea and what to do

At what BP is hypotension considered?

Symptoms of hypotension and what to do

Symptoms of HTN and what to do

How wouldyou describe the following vital signs?BP 90/60,P 106, R 30 and shallow, T 36.8oC

a. hypertensive,bradycardic, eupneic, hypothermic

b.hypertensive, tachycardic, eupneic, hypothermic

c. hypotensive,bradycardic, tachypneic, hyperthermic

d.hypotensive, tachycardic, tachypneic, normothermic

1kg =? lbs

1 inch = ? cm

Android fat

Gynoid fat

Where should you hear resonant sounds when percussing?

Where should you hear hyper resonant sounds when percussing?

Where should you hear tympani sounds when percussing?

Where should you hear dull sounds when percussing?

Where should you hear flat sounds when percussing?

What kind of sounds does the diaphragm hear?

What type of sounds does the bell hear?

Whatobjective sign can be indicative of pain? Pick all that apply:

a.Tachycardia

b.Profuse sweating

c. Askingfor pain medication

d. Highblood pressure

e. Lowtemperature

f. Hypoxia

What can cause premature aging?

Labvalues: K+3.3 and Na2+ 131 The nurserecognizes that these values are _________And it isimportant to maintain an expected range for proper:

a.Tissuerepair

b.Hairgrowth

c.Oilproduction in skin

d.Fluid andelectrolyte function.

A patientcomes into the ER complaining of chest pain and states he has noticed blood inhis bowel movements for the last 2 days. What lab result would the nurse be most concerned about?

a.RBC

b.WBC

c.HGB

d.Na

The nursenotes that the patient has an irregular heart rate. What lab work should thenurse consider and why? And what other blood work might produce and irregular heart rate?

A.Hgbbecause the patient may be bleeding

B.WBCbecause the patient may have a infection.C.Nabecause the patient may be hyponatremic.D.Mgbecause it may cause neuromuscular excitabilility.

Abdomen

Viscera

Solid Viscera

Hollow Viscera

A pt is hospitalized with vomiting of coffee groundsemesis of unknown cause. Which disgnostic test should be done to identify the source ofbleeding?

What is most important for the nurse ot obtain duringinitial assessment of a pt admitted toER with vomiting of bright red blood?

Nurse suspect E.Colo food poisoning. What types of symptoms will the pt’s have?

Which stool consistency would the nurse expect to seein sigmoid colostomy?

Pt admitted to hospital with UC and having 14-16 bloodystools a day. What should the nurse plan to implement?

Newly diagnosed pt with Crohn’s asks what to expect in the future. Best Response:

What does the frontal lobe control?

What does the parietal lobe control?

What does the temporal lobe control?

What does the occipital lobe control?

What does the basal ganglia do?

What does the thalamus do?

What does the hypothalamus do?

4 areas of the brainstem:

What does the cerebellum do?

Which nerves are included in the PNS?

What areas are considered to bepart of the Central Nervous System?Select all that apply.A.Brain

B.Meninges

C.Spinal Cord

D.Cranial nerve pair VII

E.Cerebellum

Break down the 31 pairs of spinal nerves into cervical, thoracic, lumbar, sacral and coccygeal

Your patient was in an MVA and hadthe spinal cord completely severed at L4. Select which corresponding myotome would be affected?

A.Legs

B.Abdomen

C.Chest

D.Head

What are the 3 layers of the meninges?

Where on the spine is a lumbar puncture done?

What are the 2 major pairs of arteries that supply blood to the brain?

The vertebral arteries merge to form which artery?

What artery supplies blood to theanterior portion of the brain?

A.Vertebral arteries

B.Spinothalmic arteries

C.Basilar arteries

D.Internal Carotid arteries

What is the penumbra region with a stroke?

What is the drug of choice for strokes?

Hemiplegia

Hemiparesis

Hemineglect

Dysphagia

Contralateral

Ipsilateral

Aphasia

Expressive aphasia

Receptive aphasia

Amnesia

Global aphasia

Dysarthria

Parasthesia

agnosia

Homonymous hemianopsia

What happens with left hemisphere damage?

What happens with right hemisphere damage?

Primary prevention of strokes:

3 components in the skull:

What is the Monro-Kellie Hypothesis?

Normal range for ICP:

What is Cerebral blow flow?

How often is a neuro recheck done?

What is the single most important factor in the neuro recheck?

Which of the following lab values would the nurse expect to see in a patient with long-standing COPD? Choose all that apply.Select one or more:

a. elevated pC02 (hypercapnia)

b. decreased bicarbonate level (HC03)

c. hypoxemia

d. elevated pa02

e. polycythemia

f. decreased hemoglobin

What is for pulmonale?

Contraindications of percussion/vibration:

contraindications of postural drainage:

A person who is the "yellow zone" of the Asthma Action Plan is experiencing symptoms of asthma along with increased need for a short-acting:

Which of the following are clinical manifestations of asthma? Choose all that applySelect one or more: a. prolonged inspiratory phase of breathingb. wheezingc. breathlessnessd. coughing that occurs predominantly in the middle of the daye. coughingf. sensation of chest tightness

A patient with COPD is sitting up in a chair, complaining of dyspnea, and very restless. Oxygen saturation is 85%. Which of the following nursing interventions is a priority?Select one:a. Administer prn salbutamol nebulizerb. Notify the physician.c. Assist patient to assume position of comfortd. Administer oxygene. Perform a focussed respiratory assessment.

An acute exacerbation of COPD is defined as ... (choose all that apply)Select one or more:a. sustained worsening of coughb. sustained worsening of sputum productionc. sustained need for supplemental oxygend. sustained worsening of dyspneae. sustained need for bronchodilator therapy

When assessing a patient neurologically, the nurse notes uncoordinated movement of extremities. The nurse would document this asSelect one:a. Ataxia Correctb. Apraxiac. Anosognosiad. Anisocoria

As people age, several neurological changes occur. Neurons, brain size, and neurotransmitters decrease. What are some of the results of aging on the neurological system?Select one or more:a. reduced response to stimuli b. inability to process nutrientsc. More frequent seizuresd. delayed reflexes e. slower thought processes

Intracranial pressure is the combination of the force measured in the brain exerted by which components?Select one or more:a. Brain tissue Correctb. Blood c. Lymphatic tissued. Dura Matere. Cerebral spinal fluid

A nurse is teaching a small group of older adults about the early warning signs of a stroke. Which of the following would be included in this teaching?Select one or more:a. Sudden numbness or weakness of the face, arm, or leg, especially on one side of the body b. Pain in the left arm radiating to the neck and jawc. Sudden trouble seeing in one or both eyes d. Sudden trouble walking, dizziness, or loss of balance or coordination

Which of the following risk factors for stroke would be MOST important for the nurse to include when planning a community education program?Select one:a. Hypertensionb. Hyperlipidemiac. Oral contraceptives d. Alcohol consumption

A nurse is assessing a client with emphysema. The nurse should report which of the following client assessment findings?a. Fatigueb. Cyanotic lipsc. Barrel-shaped chestd. Crackles in posterior chest

A nurse is providing instruction to a client on how to use montelukast (Singulair) to treat chronic asthma. The nurse should recognize that the client understands the teaching when he states,a. "I will take this medication with each meal."b. "I will take this medication during my asthma attacks."c. " I will take this medication up to three times a day when I begin to wheeze."d. " I will take this medication every evening, even when I do not have symptoms."

A nurse should take which of the following action when providing endotracheal suctioning for a client who is in respiratory distress?a. Suction the client's endotracheal tube using clean techniqueb. Remove the suction catheter using a rotating motionc. Suction the oropharyngeal cavity prior to suctioning the endotracheal tubed. Suction the client's endotracheal tube every 2 hr.

A nurse is caring for a client in respiratory distress. Which of the following devices should the nurse use to provide the highest level of oxygen via a low-flow system?a. Nasal cannulab. Nonrebreather maskc. Simple face maskd. Partial rebreather mask

A nurse is positioning a client with emphysema to promote effective breathing. The nurse should place the client in which of the following positions?a. Lateral position with a pillow over the chest to support the armb. High-Fowler's position with arms supported on the overbed tablec. Semi-Fowler's position with pillows supporting both armsd. Supine position with the head of the bed elevated 15 degrees

A nurse is caring for a client with adult respiratory distress syndrome (ARDS). Which of the following assessment findings indicates that the client's work of breathing has worsened?a. Increase in respiratory rateb. Increase in oxygen saturationc. Decrease in carbon dioxide retentiond. Decrease in adventitious breath sounds

A nurse is caring for a client who has COPD. Which of the following findings should the nurse report to the primary care provider?a. An oxygen saturation of 89%b. Productive cough with green sputumc. Clubbing of fingersd. Use of pursed-lip breathing with exertion

A nurse should plan to administer which of the following medications to a client during an acute asthma attack?a. Cromolyn sodium (Intal)b. Albuterol (Proventil)c. Fluticasone and salmeterol (Advair Discus)d. Prednisone (Deltasone)

Which is administered first: the bronchodilator or the corticosteroid?

A client has been started on long-term therapy with rifampin (Rifadin). A nurse teaches the client that the medicationa. Should always be taken with food or antacidsb. Should be double-dosed if one dose is forgottenc. Causes orange discloration of sweat, tears, urine, and fecesd. May be discontinued independently if symptms are gone in 3 months

A nurse has given a client taking ethambutol (Myambutol) information about the medication. The nurse determines that the client understands the instructions if the client states to report immediately:a. Impaired sense of hearingb. Gastrointestinal side effectsc. Orange-red discoloration of body secretionsd. Difficulty in discriminating the color red from green

A nurse teaches a client about the effects of diphenhydramine (Benadryl), which has been prescribed as a cough suppressant. The nurse determines that the client needs further instructions if the client states that he or she will:a. Take the medication on an empty stomachb. Avoid using alcohol while taking this medicationc. Use sugarless gum, candy, or oral rinses to decrease dry mouthd. Avoid activities requiring mental alertness while taking this medication

A nurse is preparing to administer a dose of naloxone hydrochloride (Narcan) intravenously to a client with an intravenous opioid overdose. Which supportive medical equipment would the nurse paln tohave at the client's bedside if needed?a. Nasogastric tubeb. Paracentesis trayc. Resuscitation equipmentd. Central line insertion tray

A nurse is instructing a hospitalized client with a diagnosis of emphysema about measures that will enhance the effectiveness of breathing during dyspneic periods. Which of the following positions will the nurse instruct the client to assume?a. Sitting up in bedb. Side-lying in bedc. Sitting in a reclinerd. Sitting on the side of the bed and leaning on the overbed table

An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which oxygen delivery system would the nurse anticipate to be prescribed?a. Face tentb. Venturi maskc. Aerosol Maskd. Tracheostomy collar

A nurse is assessing a client with chronic airflow limitation and notes that the client has a "barrel chest." The nurse interprests that this client has which of the following forms of chronic airflow limitation?a. Emphysemab. Bronchial asthmac. Chronic obstructive bronchitisd. Bronchial asthma and bronchitis

A nurse instructs a client to use the pursed-lip method of breathing and the client asks the nurse about the purpose of this type of breathing. The nurse responds, knowing that the primary purpose of pursed-lip breathing is to:a. Promote oxygen intakeb. Strengthen the diaphragmc. Strengthen the intercostal musclesd. Promote carbon dioxide elimination

The nurse is reviewing the arterial blood gas results for a 25-year-old trauma patient who has new onset of shortness of breath and demonstrates shallow and irregular respirations. The pH is 7.26. What imbalances does the nurse suspect this patient has?a. Respiratory acidosisb. Respiratory alkalosisc. Metabolic acidosisd. Metabolic alkalosis

The nurse makes observations about several respiratory patients' abilities to perform activities of daily living in order to quantigy the level of dyspnea. Which patient is considered to have Class V dyspnea?a. Experiences subjective shortness of breath when walking up a flight of stairsb. Limited to bed or chair and experiences shortness of breath at restc. Can independently shower and dress, but cannot keep pace with similarly aged peopled. Experience shortness of breath during aerobic exercise such as jogging

For a healthy adult, what is the expected normal range for the respiratory rate per minute?a. 10 to 12b. 12 to 15c. 12 to 20d. 20 or more

What is a pulse oximeter used to mesure?a. Oxygen perfusion in the extremitiesb. Pulse and perfusion in the extremitiesc. Generalized tissue perfusiond. Oxygen saturation in the red blood cells

The patient with chronic respiratory disease presents with a decreased level of consciousness, dusky skin, pale mucous membranes, decreased capillary refill, and an increased respiratory rate. What is the priority nursing diagnosis?a. Ineffective airway clearanceb. Ineffective tissue perfusionc. Decreased cardiac outputd. Acute confusion

The nurse reviews the complete blood count results for the patient who has chronic obstructive pulmonary disease (COPD) and lives in a high mountain area. What lab results does the nurse expect to see for this patient?a. Increased red blood cellsb. Decreased neutrophilsc. Decreased eosinophilsd. Increased lymphocytes

Which assessment finding is an objective sign of chronic oxygen deprivation?a. Continuous cough productive of clear sputumb. Audible inspiratory and expiratory wheezec. Chest pain that increases with deep inspirationd. Clubbing of fingernails and a barrel-shaped chest

What observations does the nurse make when performing a general assessment of the patient's lungs and thorax? (Select all that apply)a. Symmetry of chest movementb. Rate, rhythm, and depth of respirationsc. Use of accessory muscles for breathingd. Comparison of the anteroposterior diameter with the lateral diametere. Measurement of the length of the chestf. Assessment of chest expansion and respiratory excursion

The nurse is taking a history on a patient who reports sleeping in a recliner chair at night because lying on the bed causes shortness of breath. How is this documented?a. Orthopneab. Paroxysmal nocturnal dyspneac. Orthostatic nocturnal dyspnead. Tachypnea

Upon assessing the lungs, the nurse hears short, discrete popping sounds "like hair being rolled between fingers near the ear" in te bilateral lower lobes. How is this assessment documented?a. Rhonchib. Wheezesc. Fine cracklesd. Coarse crackles

What is the characteristic of normal lung sounds that should be heard throughout the lung fields?a. Short inspiration, long expiration, loud, harshb. Soft sound, long inspiration, short quiet expirationc. Mixed sounds of harsh and soft, long inspiration and long expirationd. Loud, long inspiration and short, loud expiration

The nurse is performing a physical assessment of the respiratory system. Although the patient is currently confined to bed, he has the strength and mobility to move and reposition himself. The nurse instructs him to assume which position for the assessment?a. Side-lyingb. Semi-Fowlersc. Supined. Sitting upright

The older patient is confined to bed and is therefore prone to decreased alveolar surface and elastic recoil. Which intervention is best to address these physiologic changes?a. Adequate nutritional intakeb. Coughing and deep breathingc. Fluids to thin secretionsd. Periods of rest and sleep

The patient demonstrates labored shallow respirations and a respiratory rate of 32/min with a pulse oximetry reading of 85%. What is the priority nursing intervention?a. Notify respiratory therapy to give the patient a breathing treatmentb. Start oxygen via nasal cannula at 2L/minc. Obtain an order for a stat arterial blood gas (ABG)d. Encourage coughing and deep-breathing exercises

The patient's pulse oximetry reading is 89%. What is the nurse's priority action?a. Recheck the reading with a different oximeterb. Apply supplemental oxygen and recheck the oximeter reading in 15 minutesc. Assess the patient for respiratory distress and recheck the oximeter readingd. Place the patient in the recovery position and monitor frequently

The nurse is assessing an older adult patient who reports a decreased tolerance for exercise and that she must work harder to breathe. Which question assists the nurse in determining if these are normal changes related to aging?a. "How old are you?"b. "When did you first notice these symptoms?"c. "Do you or have you ever smoked cigarettes?"d. "How often do you exercise?"

The nurse is caring for the older adult who is temporarily confined to bed. Which intervention is important in promoting pulmonary hygiene related to age and decreased mobility?a. Obtain an order for PRN oxygen via nasal cannulab. Encourage the patient to turn, cough, and deep breathe.c. Reassure the patient that immobility is temporaryd. Monitor the respiratory rate and check pulse oximetry readings.

The patient comes to the physician's office for an annual physical. The patient reports having a persistent nagging cough. Which question does the nurse ask first about this symptom?a. "When did the cough start?"b. "Do you have a family history of lung cancer?"c. "Have you been running a fever?"d. "Do you have sneezing and congestion?"

1. The nurse assesses a patient with shortness of breath for evidence of long-standing hypoxemia by inspecting: A. Chest excursion B. Spinal curvatures C. The respiratory pattern D. The fingernail and its base

6. The nurse is caring for a patient admitted to the hospital with pneumonia. Upon assessment, the nurse notes a temperature of 101.4° F, a productive cough with yellow sputum and a respiratory rate of 20. Which of the following nursing diagnosis is most appropriate based upon this assessment? A. Hyperthermia related to infectious illness B. Ineffective thermoregulation related to chilling C. Ineffective breathing pattern related to pneumonia D. Ineffective airway clearance related to thick secretions

7. Which of the following physical assessment findings in a patient with pneumonia best supports the nursing diagnosis of ineffective airway clearance? A. Oxygen saturation of 85% B. Respiratory rate of 28 C. Presence of greenish sputum D. Basilar crackles

Circular flatdiscoloration,<1 cm brown, blue, redor hypopigmented

Circular, elevated, solidlesion, >1cm

Circumscribed flatdiscoloration, >1cm

Superficial solidelevated, ≤0.5 cm,color varies

Superficial elevatedsolid flat toppedlesion, >1 cm

Vesicle containingpus (inflammatorycells)

Circular collection offree fluid, ≤1 cm

Edematous, transitoryplaque, may last fewhours

Linear erosion

Loss of epidermis (superficial);Part or all of the epidermis hasbeen lost

Thickening of theepidermis seen withexaggeration of normalskin lines

round or circular with centralclearing

round, circular > arciform: partialcircle

connecting arcs

meandering; wander as though following the track of a snake.

Jane Smith, age 30, is admitted tohospital with an asthma attack. She has audible wheezing, dyspnea, and isextremely anxious. She can speak only one to three wordsentences. RR: 34/ min.Auscultation reveals no air entry in lower lobes. 1.Whatare nursing care priorities?

Jane Smith, age 30, is admitted to hospital with an asthma attack. She has audible wheezing, dyspnea, and is extremely anxious. She can speak only one to three word sentences. RR: 34/ min. Auscultation reveals no air entry in lower lobes.2.What complications could occur based on assessment data?

Jane Smith, age 30, is admitted to hospital with an asthma attack. She has audible wheezing, dyspnea, and is extremely anxious. She can speak only one to three word sentences. RR: 34/ min. Auscultation reveals no air entry in lower lobes.3.What should be included in the discharge plan?

Where does gas exchange occur?

What words are used during palpable assessment for tactile fremitis:

When would there be increased fremitus?

When would there be decreased fremitus?

What sound should you hear when percussing the thorax?

Where are bronchial sounds heard? What do they sound like? What is the length of inspiration and expiration?

Where are bronchovesicular sounds heard? What do they sound like? What is the length of inspiration and expiration?

Where are vesicular sounds heard? What do they sound like? What is the length of inspiration and expiration?

Normal breath sounds are described by what 3 things?

What are the 3 types of voice sounds?

What do fine crackles sound like?

What do coarse crackles sound like?

What does a stridor sound like? Where do you hear it?

What does a pleural friction rub sound like?

Apnea:

hypopnea:

What can occur during sleep apnea?

People with increased risk of sleep apnea with:

How long does sleep apnea last during an apnea stage?

People with sleep apnea are at a higher risk of which cardiovascular events?

2 appliances used for sleep apnea?

COPD

S&S of COPD

Advanced disease of COPD can also cause what else within the body?

2 conditions associated with COPD:

emphysema:

chronic bronchitis:

Causes of COPD:

Defining feartures of COPD:

Hypoxia

S&S of asthma:

Apatient is admitted to hospital with acute exacerbation of COPD related toinfluenza. ABGs and CXR are ordered and Sa02 is 86%. BP 168/102, P 104, RR 28•Whatis your priority intervention? a. Administer antihypertensiveb. Apply oxygen via nasal prongs at2L/min c. Apply non-rebreather maskd. Administer bronchodilator

What is the rate of flow for nasal prongs?

What is the rate of flow for a simple mask?

What is the rate of flow for a non-rebreather?

Superficial spreading melanoma (SSM):

Lentigo maligna melanoma (LMM):

Acral-lentiginous melanoma (ALM):

Nodular melanoma (NM):

Basal cell carcinoma

Squamous cell carcinoma-

Edema stages

edema

Mobility of skin

skin turgor

Example of an annular or circular shaped lesion

Confluent lesions

Dicrete lesions

Grouped lesions

Gyrate, Serpinginous lesions

Polycyclic lesions

Zosteriform lesions

Macule

papule

nodule

Wheal

vesicle

Cyst

Pustule

Patch

Lichenification

Exoriation

Crust

Keloid

Fissure

erosion

ulcer

Vitiligo

Lentigo

petechiae

purpura

superficial wounds

partial thinkness wounds

full thickness wounds

How long do acute wounds take to heal?

What is a chronic wound?

Key prevention for pressure ulcers:

stages of pressure ulcers: