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Nursing Process: Diagnosis Stage and Cardiovascular Conditions, Exams of Nursing

Answers to various questions related to the diagnosis stage of the nursing process, focusing on cardiovascular conditions. Topics include causes and effects of hypotension, acute myocardial infarction, hemorrhage, vasodilation, addison's disease, and smoking's impact on blood pressure. Additionally, it covers physiological changes associated with acute pain responses and manifestations of breast cancer.

Typology: Exams

2023/2024

Available from 03/23/2024

david-ndembu
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NR 304 COMPREHENSIVE PREDICTOR QUESTIONS
AND ANSWERS FOR FINAL EXAM
1. Progress towards outcomes, use ongoing assessment to revise
diagnoses/outcomes/plans, disseminate results to patient and family - ANSWER
What happens during the evaluation step of the nursing process?
2. Compare clinical findings with normal and abnormal variation and developmental
events, interpret data, validate and document diagnoses. - ANSWER What
happens during the diagnosis stage of the nursing process?
3. For limited or short term problems. Collect mini/targeted databases. Focuses on
only one problem or body system and is used in all clinical settings.
4. Ex: two days post-op patient suddenly becomes SOB with congestive cough and
fatigue; focus on respiratory and cardiovascular systems - ANSWER What is a
problem center database? Give an example.
5. Begins during first patient encounter.. Includes their physical appearance, body
structure, mobility, behavior, body measurements - ANSWER What are the
components of a general survey?
6. 3+ Full, bounding
7. 2+ Normal
8. 1+ Weak, thready
9. 0 Absent - ANSWER What is the grading of pulse force?
10. Acute myocardial infarction, shock, hemorrhage, vasodilation, Addison's disease
- ANSWER What are causes of hypotension?
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NR 304 COMPREHENSIVE PREDICTOR QUESTIONS

AND ANSWERS FOR FINAL EXAM

  1. Progress towards outcomes, use ongoing assessment to revise diagnoses/outcomes/plans, disseminate results to patient and family - ANSWER What happens during the evaluation step of the nursing process?
  2. Compare clinical findings with normal and abnormal variation and developmental events, interpret data, validate and document diagnoses. - ANSWER What happens during the diagnosis stage of the nursing process?
  3. For limited or short term problems. Collect mini/targeted databases. Focuses on only one problem or body system and is used in all clinical settings.
  4. Ex: two days post-op patient suddenly becomes SOB with congestive cough and fatigue; focus on respiratory and cardiovascular systems - ANSWER What is a problem center database? Give an example.
  5. Begins during first patient encounter.. Includes their physical appearance, body structure, mobility, behavior, body measurements - ANSWER What are the components of a general survey?
  6. 3+ Full, bounding
  7. 2+ Normal
  8. 1+ Weak, thready
  9. 0 Absent - ANSWER What is the grading of pulse force?
  10. Acute myocardial infarction, shock, hemorrhage, vasodilation, Addison's disease
    • ANSWER What are causes of hypotension?
  1. Less than 95/60 mmHg - ANSWER What is the blood pressure measurement for hypotension?
  2. Decreased - ANSWER Acute myocardial infarction and shark causes a _____ cardiac output which leads to hypertension?
  3. decreased - ANSWER Hemorrhage causes a _____ total blood volume that leads to hypotension
  4. decreased - ANSWER Vasodilation causes a ____peripheral vascular resistance that leads to hypotension
  5. decreased - ANSWER Addison's disease (hypofunction of adrenal gland) is caused by a ___ circulating aldosterone which causes hypotension
  6. Count while assessing radial pulse to make patient unaware that you were counting respirations. Count for 30 seconds of normal or 1 minute if abnormal - ANSWER How do you count respirations?
  7. Vasoconstriction of the arteries which makes your blood pressure increase. Long-term cause of hypertension - ANSWER What are the effects of smoking on blood pressure?
  8. Asymmetry, border irregularity, color variation, diameter greater than 6mm, elevation/evolution, funny looking - ANSWER What is the ABCDEF skin lesions mean?
  9. Tachycardia, elevated blood pressure, increased cardiac output, hypoxia, hypoventilation, atelectasis, decreased cough, nausea, vomiting, ileus, oliguria, urinary retention, spasm, joint stiffness, increased adrenergic activity, fear,
  1. Stage 1 non-blanchable erythema
  2. Intact skin with a localized area of non-blanchable erythema - ANSWER What is the name and characteristics of a stage one pressure injury?
  3. Stage 2 partial thickness skin loss
  4. Partial skin loss with an exposed dermis. Pink/red and moist visible wound base. Looks like a ruptured blister. Usually associated with moisture. Slough and eschar not noted. - ANSWER What is the name and characteristics of a stage 2 pressure injury?
  5. Stage 3: Full-Thickness Skin Loss
  6. For thickness loss of skin. Adipose is visible in ulcer and granulation tissue with epibole. Slough and eschar may be noted. Tunneling and undermining may occur. - ANSWER What is the name and characteristics of a stage 3 pressure injury?
  7. Stage 4: Full thickness skin/tissue loss
  8. Full thickness skin and tissue loss with muscle/bone/tendon/ligament exposed. Slough, Eschar, epibole, undermining, tunneling may be present. - ANSWER What's the name and characteristic of a stage 4 pressure injury?
  9. Touch chin to chest, turn head right and left, touch ear with shoulder without elevating the shoulders, extend head backwards - ANSWER How do you assess the range of motion of the neck?
  10. Non-pitting Edema, fatigue, cold intolerance, puffy Edematous face, Peri orbital Edema, puffy hands/feet, course facial/hair features, cool/dry skin, slow reflexes,

occasionally thick speech. - ANSWER What are the manifestations of hypothyroidism?

  1. Firm/hard irregular axillary node, skin dimpling, nipple retraction, elevation, discharge - ANSWER What are the manifestations of breast cancer?
  2. Lymphedema due to the decrease number of lymph nodes - ANSWER What are the complications of a mastectomy?
  3. Note shape and configuration of chest wall, anteroposterior (AP) diameter should be less than transverse diameter (if more=barrel chest), note breathing position, skin color and condition ( cyanosis=hypoxia) - ANSWER What are the inspection techniques for the thorax and lungs?
  4. Connected, musical sounds, sounds like a kazoo - ANSWER Describe wheezing?
  5. Discrete, crackling sound. Popping/crackling - ANSWER Describe crackles?
  6. Pulmonary edema, pneumonia, pulmonary fibrosis, terminally ill with depressed cough reflex, heart failure, interstitial fibrosis, chronic bronchitis, asthma - ANSWER What clinical patients would you expect to have Adventitious lung sounds of crackling?
  7. Rapid, shallow breathing, increase rate. 24+ BPM. Normal response to fever, fear, exercise. Occurs with respiratory insufficiency, pneumonia, alkalosis, pleurisy, pons lesions. - ANSWER What are the indications of tachypnea and when do they occur?
  8. 95% of the time due to a DVT, hypoxia, decreased cardiac output, Dyspnea, chest pain that's worse on inspiration, apprehension, restlessness, anxiety,
  1. Unstageable angina and myocardial infarction - ANSWER What is acute coronary syndrome?
  2. Indigestion feeling, nausea, vomiting, dizzy, flushing, perspiration, palpitations, fatigue, Dyspnea - ANSWER What are the manifestations of acute coronary syndrome (MI)?
  3. Any leg pain or cramps, skin changes on arms/legs, swelling of arms/legs, lymph node enlargement, medication, smoking history - ANSWER What are types of subjective questions that you would ask during a peripheral vascular exam?
  4. Clubbing, capillary refill, pulse, modified Allen test, hair distribution, palpate temperature, test for edema, color changes, DVT risk - ANSWER What assessments would you do during a peripheral vascular exam?
  5. Assess DVT risk
  6. 1 - 2= moderate risk
  7. 3+= high risk - ANSWER What is the Wells Score used to identify? What do the scale ratings mean?
  8. Occlude ulnar and radial arteries while person makes a fist, the color should return in less than seven seconds - ANSWER What is the modified Allen test and what is a normal reading?
  9. ineffective peripheral tissue perfusion - ANSWER Give a nursing diagnosis for lymphedema
  10. Elevation, flying, walking, pain medication - ANSWER What are relieving factors for venous insufficiency?
  1. Aching, calf heaviness, restless legs, burning, throbbing, cramping, dilated/tortuous veins, new ones sit on the surface of muscle or bones and old ones are deep and feel spongy - ANSWER What are the manifestations of varicose veins?
  2. Sudden onset of intense/sharp deep muscle pain, increased warmth, swelling, redness, dependent cyanosis is mild to absent, tender to palpation - ANSWER What are the manifestations of a DVT?
  3. Clot travels and increases the risk of a pulmonary embolism - ANSWER Where are the complications of a DVT?
  4. Immobility, prolonged bed rest, history of varicose veins, trauma, infection, cancer, obesity, heart failure, estrogen use - ANSWER What are the risk factors for DVT?
    • Skeletal muscle contraction milks blood proximally towards heart
    • pressure gradient by breathing (inspire=decreased thoracic pressure and increased abdominal pressure)
    • Intraluminal valves to prevent backflow - ANSWER What are the three mechanisms of venous return?
  5. Plaque development in arteries - ANSWER What is the risk of atherosclerosis?
  6. Edema, varicosities, weeping ulcers at ankles - ANSWER What are the manifestations of chronic venous disease?
  7. 1+: mild pitting, slight indentation, no perceptible leg swelling
  8. 2+: moderate pitting, indentation rapidly subsides
  9. 3+: deep pitting indentation remains for a short time, legs look swollen

dehydration - ANSWER What are the physical exam findings associated with intestinal/bowel obstruction?

  1. Abdominal surgery history with adhesions, vomiting, fever, absent stool/gas, colicky pain from strong peristalsis above obstruction, distention, hyperactive bowel sounds early, hypoactive bowel sounds late, tenderness, hypovolemic shock from dehydration - ANSWER What are the manifestations of an intestinal/Bowel obstruction?
  2. Pain when palpating the liver means gallbladder is inflamed cholecystitis, hold fingers under liver border and ask patient to take a deep breath. Normal=no pain. Positive=sharp pain that indicates cholecystitis - ANSWER What are positive Murphy's sign indications? How do you test for it?
  3. Bored like a hardness of muscles. Protective mechanism for acute peritonitis. Unilateral - ANSWER What does involuntary rigidity mean?
  4. Occurs when a patient is cold, tense, or ticklish.Bilateral. Feels muscles relax on exhale - ANSWER What does voluntary guarding mean?
  5. Weakness, redness, joint swelling, heat, pain - ANSWER What are the early manifestations of rheumatoid arthritis?
  6. Anorexia, weight loss, ulnar drift, swan neck, boutonniere deformity - ANSWER What are the light manifestations of rheumatoid arthritis
  7. Kyphosis - ANSWER What is spinal deformity's associated with osteoarthritis?
  8. Post menopausal white women, smaller height and weight, younger age at menopause, lack of physical activity, lack of estrogen - ANSWER What are the risk factors for osteoporosis?
  1. Olfactory S: eyes closed and place familiar smells under the nose and see if it's identified by patient. Not routinely assessed - ANSWER What is cranial nerve one and how do you assess it?
  2. Optic S: test visual acuity and field by using ophthalmoscope to examine ocular fundus to determine color, size, shape of optic disc - ANSWER What is cranial nerve two and how do you assess it?
  3. Oculomotor M: use penlight to assess people are construction. PERRLA. Assess CN 3,4,6 together - ANSWER What is cranial nerve three and how do you assess it?
  4. Trochlear M: move eyes down to the tip of nose. Six Cardinal fields of gaze - ANSWER What is cranial nerve for and how do you assess it?
  5. Abducens M: moves eyes to the sides. Six cardinal fields of gaze - ANSWER What is cranial nerve six and how do you assess it?
  6. Trigeminal B: palpate masseter muscle and have patient clenched teeth (M). Have patient close their eyes and touch cotton ball on forehead, cheeks, chin bilaterally (S). - ANSWER What is cranial nerve five and how do you assess it?
  7. Facial B: have patient smile, frown, puff cheeks, raise eyebrows - ANSWER What is cranial nerve seven and how do you access it?
  8. Acoustic/vestibulocochlear S: voice whisper test - ANSWER What is cranial nerve eight and how do you assess it?
  9. CN 9: Glossopharyngeal B & CN 10: Vagus B: stick tongue out and say AHH note uvula and soft palate rise midline. Ask patient to swallow - ANSWER What are cranial nerves 9 and 10 and how do you assess them?
  1. Sudden/severe headache, nausea, vomiting, sudden LOC, focal seizures - ANSWER What are the manifestations of a hemorrhagic stroke?
  2. Unilateral face droop, arm drift, weakness or paralysis on one side of the body, difficulty speaking or understanding speech, confusion, sudden onset of dizziness, loss of balance, cloudy vision - ANSWER What are the manifestations of an ischemic a stroke?
    • Sudden loss of blood flow to the brain. - Thrombotic results from atherosclerosis. - Embolic caused by a traveling clot. - ANSWER What are the causes of an ischemic? What are the two types and their causes?
  3. Caused by a rupture and bleeding from a weakened artery in the brain - ANSWER What is the cause of a hemorrhagic stroke?
  4. Have patient stand with feet together and arms by their side with eyes closed for 20 seconds. Nurse should monitor while counting for 20 seconds and stand with arms around the patient with a gap between them. - ANSWER How do you perform the Rhomberg test? a. More than normal swaying - ANSWER What is indicated by a positive Rhomberg test?