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NUR 120 Exam
___________________: controls both voluntary and involuntary actions and movements. It is divided into two branches _________________ & _________________ ANS: -Nervous system -Central nervous system -Peripheral nervous system QUIZ: ____________________: which includes the brain and the spinal cord. ANS: CNS QUIZ: ____________________: which is comprised of nerves which communicate (send signals) between the brain / the spinal cord and the rest of your body. ANS: PNS QUIZ: Which cranial nerve (CN) does the nurse test on a patient when biting down on a tongue blade? a. CN V b. CN VI c. CN VII d. CN VIII ANS: A QUIZ: When performing the Romberg test, the nurse instructs the client to: a. tandem walk. b. hop on one foot. c. do a deep knee bend. d. stand with feet together, eyes open then closed. ANS: D QUIZ: What is the Rhomberg test? ANS: Patient stand with arms straight out to each side with feet together and instructed to close both eyes while standing in that position. Observe for steadiness QUIZ: For a Rhomberg test, what is considered normal? ANS: A negative test QUIZ: During the Rhomberg test, if the hands (palms facing up) drifted that would indicate what? ANS: A stroke QUIZ: On the DTR Grading Scale, what is considered normal? ANS: 2+ = normal QUIZ: Which of the following reflexes would be considered abnormal in an adult? a. Anal. b. Biceps. c. Plantar. d. Babinski. ANS: D QUIZ: What is a positive Babinski? ANS: Toes fan out
QUIZ: Is a positive Babinski abnormal or normal? ANS: Abnormal QUIZ: What are the functions of the skeletal system? ANS: -Support and protect the body -Aid in movement -Store nutrients -Produce blood cells QUIZ: What is the muscular system responsible for? ANS: -Body movements -Stability -Internal movement of substances within the body QUIZ: What is abduction? ANS: Limb away from body QUIZ: What is adduction? ANS: Limb towards body QUIZ: What is circumduction? ANS: Limb movement in circular motion QUIZ: What is extension? ANS: Straighten out limb QUIZ: What is flexion? ANS: Bend limb QUIZ: What is Hyperextension of neck? ANS: Lift your head and look up at the ceiling QUIZ: What is external rotation? ANS: Turn hip join outward QUIZ: What is internal rotation? ANS: Turn hip joint inward QUIZ: What is eversion? ANS: Hand or foot turn away body QUIZ: What is inversion? ANS: Hand or foot turn towards body QUIZ: What is pronation? ANS: Palm facing down QUIZ: What is supination? ANS: Palm facing up QUIZ: What is dorsiflexion? ANS: Bend foot toward knees QUIZ: What is plantar flexion? ANS: Point foot toward ground QUIZ: To determine the degree of joint limitation for a patient with a long history of arthritis complaining of sensitivity and warmth in the knees, the nurse should assess: a. Posture. b. Activity tolerance.
QUIZ: If Vitamin K1 is unable to control the bleeding, what can u administer to control the bleeding? (Warfarin) ANS: Fresh frozen plasmas or whole blood (high INR) QUIZ: When the nurse assesses an immobile patient, what is one effect of immobility on the cardiovascular system? a. Impaired gas exchange. b. Increased risk for contractures. c. Increased bone mineralization. d. Increased risk for venous thrombosis. ANS: D QUIZ: What is a superficial pain? ANS: Arises in the skin or the subcutaneous tissue (ex. a burn or an abrasion). Although the injury is superficial it may cause significant short-term pain QUIZ: What is somatic pain? ANS: -Originates in the ligaments, tendons, nerves, blood vessels and bones. Deep somatic pain is more diffuse than cutaneous pain & tends to last longer. -Ex. fractures, sprains, arthritis, & bone cancer -More localized/internal QUIZ: What is visceral pain? ANS: -Stimulation of deep internal pain receptors, most often in the abdominal cavity, cranium, or thorax. Vary from local, achy discomfort to more widespread, intermittent, and crampy pain. -Ex. Period cramps, labor pain, GI infections, bowel disorders, organ cancer -Specific parts of the body QUIZ: What is radiating pain? ANS: -Starts @ origin but extends to other locations. -Ex. the pain of a severe sore throat may extend to the ears & head, or the pain of heart burn may radiate outward from sternum to involve the upper thorax QUIZ: What is referred pain? ANS: -Occurs in an area that is distant from the original site. -Ex. the pain from a heart attack may be experienced down the left arm, through the back or into the jaw QUIZ: What is phantom pain? ANS: Pain that perceived to originate from an area that has been surgically removed. Pts with amputated limbs may still perceive that the limb exists & experience burning, itching, & deep pain in that area QUIZ: What is psychogenic pain? ANS: Pain that's believed to arise from the mind. The pt perceives the pain despite the fact that no physical cause can be identified can be just as severe as pain from a physical cause. QUIZ: Which of the following are opioid analgesic medications that may be used for pain management? SELECT ALL THAT APPLY
a. Acetaminophen b. Morphine c. Hydromorphone d. Ibuprofen e. Oxycodone ANS: B, C, E QUIZ: True or False: A large percentage of hospitalized pts become addicted to analgesic medications ANS: False QUIZ: What is pain threshold? ANS: -Point at which brain recognizes & defines a stimulus as pain (varies from pt to pt). -Body recognize pain (ex. poke pen at hubz, but hes like meh, if it was me I would jumped, he didn't recognize the poke as pain but I did) QUIZ: What is pain tolerance? ANS: The duration or intensity of pain that a person can endure. This varies not only from person to person but also for the same person in different situations QUIZ: What is a major adverse effect associated with narcotic analgesic? ANS: Respiratory depression QUIZ: When should nurses assess pain? ANS: -During VS -When pt verbalizes pain -When checking up on the pain after administering pain meds -B4 an activity (ex. dressing change) QUIZ: The pt is unable to speak. Identify how the nurse can assess this individual's level of pain. ANS: -Nonverbal behavior -Grimacing -Body language -Facial expressions -Behavior -Assess for depression -Decreased appetite QUIZ: Which of the following nursing interventions for a pt in pain is based on the gate control theory? a. Giving the pt a back massage b. Changing the pt's position in bed c. Giving the pt a pain med d. Limiting the # of visitors ANS: A QUIZ: What is the gate control theory? ANS: -Transcutaneous electrical nerve stimulation (TENS) to relieve pain -Focus on good rather than pain
QUIZ: What is the normal BUN ranges? ANS: 7-20 mg/dL QUIZ: __________________: a waste product that is produced in the blood as a byproduct of muscle metabolism. ANS: Creatinine (Cr) QUIZ: What is the normal creatinine ranges (reliably reflects renal insufficiency)? ANS: 0.6-1.4 mg/dL QUIZ: What are the causes for Elevated BUN & Cr? ANS: Dehydration, high protein intake, impaired renal perfusion, kidney infection or inflammation, kidney obstruction, and renal failure. QUIZ: What are the causes for decreased BUN & Cr? ANS: Excess fluid intake, low protein intake, liver disease, and malnutrition. QUIZ: ____________________: assesses urine at a single point in time (screens for kidney disease, UTIs, and other conditions). ANS: Urinalysis (U/A) QUIZ: Urine dipstick: U/A ____________ , ____________ & ____________________ = UTI! ANS: - +protein
- +nitrates
- +leukocyte esterase QUIZ: What are the components of an Urinalysis? ANS: -Specific gravity -pH -Protein -Glucose -Ketones -Nitrates -Leukocyte esterase QUIZ: What is specific gravity? ANS: Balance of water and solutes QUIZ: True or False: protein is not normally in urine? ANS: True QUIZ: What is proteinuria? ANS: +protein in urine QUIZ: True or False: normal urine has little to no glucose. ANS: True QUIZ: True or False: ketones indicates fat has been broken down for energy; not normally in the urine. ANS: True QUIZ: What is Ketonuria? ANS: +ketones in urine
QUIZ: If organisms grow in the _______________ (confirms diagnosis of UTI), ______________________ is performed to determine the appropriate antibiotic therapy. ANS: -Culture -Sensitivity testing QUIZ: True or False: the general patient goal for urinary elimination is voiding comfortably approximately 1,500 mL of light yellow urine in 24-hr period. ANS: True QUIZ: How would you test Cranial Nerve I: Olfactory? ANS: Have the patient close eyes and have him/her smell a familiar scent (i.e. cinnamon, coffee, or dried orange peels). QUIZ: How would you test Cranial Nerve II: Optic? ANS: Test visual acuity with Snellen chart. QUIZ: How would you test Cranial Nerves III, IV, VI: Oculmotor, Trochlear, Abducens? ANS: -PERRLA (pupil constrict/size when light is shown & accommodation) -Cardinal directions QUIZ: How would you test Cranial Nerve V Trigeminal? ANS: -Palpate the temporal and masseter muscles as pt clenches teeth -Sensory function is checked by testing light touch sensation QUIZ: How would you test Cranial Nerve VII Facial? ANS: Ask pt to smile, frown, close eyes tightly, lift eyebrows, and puff cheeks QUIZ: How would you test Cranial Nerve VIII Acoustic? ANS: Asses the ability to hear normal conversation and whisper. Perform the Weber & Rinne QUIZ: How would you test Cranial Nerve IX, X: Glossopharyngeal, Vagus? ANS: - Gag reflex -Uvula should be midline when patient says "aah" QUIZ: How would you test Cranial Nerve XI Spinal Accessory? ANS: Ask the patient to shrug their shoulders and turn their head against resistance. QUIZ: How would you test Cranial Nerve XII Hypoglossal? ANS: Tongue should be midline when stuck out QUIZ: What is Osteoporosis (OP)? ANS: Loss of bone mass QUIZ: What is Osteoarthritis (OA)? ANS: Deterioration of joint cartilage QUIZ: ___________________, __________________, & _________________have the greatest risk for developing osteoporosis. ANS: -Asian women -Caucasian women
QUIZ: It is most important for the nurse to understand the various ways in which pain is classified so that he or she can a. Document the client's pain using accurate terms. b. Be clear in communication with the physician. c. Develop an effective pain management plan. d. Educate the client thoroughly. ANS: C QUIZ: What are the factors that influence pain? ANS: -Emotions -Past experience with pain -Developmental stage -Sociocultural factors -Communication skills -Cognitive impairments QUIZ: What is the name of the pain scale that use drawn faces? ANS: Wong-Baker QUIZ: The nurse is assessing the confused client. In trying to determine the client's level of pain, the nurse should a. Be aware that confused clients do not feel as much pain due to their confusion. b. Observe the client carefully for changes in behavior or vital signs. c. Ask the client's family how much pain the client normally has. d. Use only pain scales that feature numbers or "faces" the client can point to. ANS: B QUIZ: Mr. Zenobia's chronic cancer pain has recently increased and he asks the home health nurse what can be done. In relation to his long-acting morphine, which is an appropriate response by the nurse? a."If you take more morphine, it will not change your pain relief." b."I'll call the primary care provider and ask for an increased dose." c."The amount you are taking now is all I can give you." d."I'm worried if we increase your dose that you will stop breathing." ANS: B QUIZ: What are the Nonpharmacological measures you can take to relieve pain cutaneous stimulation wise? ANS: -Transcutaneous electrical nerve stimulation (TENS) -Percutaneous electrical nerve stimulation (PENS) -Spinal cord stimulator (SCS) -Acupuncture -Acupressure -Massage -Use of heat and cold -Contralateral stimulation -Oral sucrose -Immobilization -Cognitive-behavioral interventions -> pets, meditation
QUIZ: What is the drug class for Aspirin? ANS: COX inhibitor & salicylate QUIZ: What is the therapeutic use of Aspirin? ANS: -Antipyretic -Nonopioid analgesic -NSAID QUIZ: Whats the primary use of Aspirin? ANS: -For musculoskeletal disorders (i.e. OA & RA) -Mild-moderate pain (i.e. headache & muscle pain); -Primary dysmenorrheal pain -Reduction of fever. -Reduce the risk for mortality s/p MI and reduce the incidence for CVAs --> enteric- coated ASA if GI upset! QUIZ: What are the adverse effects of Aspirin? ANS: -Heartburn -N/V QUIZ: ___________________ ASA at high doses can cause a syndrome that includes dizziness, excessive sweating, & tinnitus. ANS: Salicylism QUIZ: What medication causes Salicylism? ANS: Aspirin QUIZ: What is the drug class for Acetaminophen? ANS: Antipyretics/non-opioid anaglesics QUIZ: What is the therapeutic use for Acetaminophen? ANS: -Analgesic (relief of pain) effect -Antipyretic (reduction of fever) effects QUIZ: What are the primary uses for Acetaminophen? ANS: -Antipyretic and for mild to moderate pain. -Great med to treat pediatric population! QUIZ: What are the contraindications for Acetaminophen? ANS: -Hypersensitivity -Severe liver impairment/disease -Kidney impariment -Pregnancy Risk Category B QUIZ: What are the adverse effects of Acetaminophen? ANS: -Adverse effects (uncommon with therapeutic doses): hepatoxicity (liver damage) in alcoholics. -ARF -Hepatic coma -Hepatoxicity. QUIZ: What is the drug class for Celecoxibs? ANS: NSAIDs (cox-2 inhibitors)
QUIZ: What is the therapeutic use for Oxycodone/Acetaminophen (Percocet) & Hydrocodone/Acetaminophen (Vicodin)? ANS: -Relief of moderate to severe pain -Sedation -Reduction of bowel motility -Cough suppression (codeine) QUIZ: What are the complications of Percocet & Vicodin? ANS: -Dizziness -Constipation -Nausea -Sedation -Coma -Circulatory collapse -Hepatoxicity -Respiratory depression -Orthostatic hypotension QUIZ: What are the contraindications for Oxycodone (Percocet & Vicodin)? ANS: - Kidney failure -Increased intracranial pressure -Biliary colic, biliary tract surgery -Pre-term labor -Use cautiously if pt has head injury, reduced respiratory reserve, C QUIZ: The nurse cares fro an injured athlete with a right leg cast. What is the term used to describe decreased muscle mass through disuse? a. Atrophy b. Spasticity c. Muscle tone d. Hypertrophy ANS: A QUIZ: The nurse assess a pt's sense of smell. What is the term used to describe this type of sense? a. Tactile b. Auditory c. Olfactory d. Gustatory ANS: C QUIZ: What be the focus assessment by the ER nurse of a potential spinal cord injury (SCI) pt who dived into shallow water? a. Reflexes b. Mental status c. Balance & gait d. Sensory perception ANS: A
QUIZ: The nurse moves a pt's arm from midline of the body. What is the term used to describe this type of movement? a. Adduction b. Abduction c. Extension d. Circumduction ANS: B QUIZ: The nurse cares for a stroke pt with left-sided weakness. What is the term used to describe this type of muscle condition? a. Atrophy b. Paraplegia c. Hemiparesis d. Hypertrophy ANS: C QUIZ: The nurse cares for an older pt with hearing impairment. Which cranial nerve is affected? a. CN I b. CN IV c. CN VIII d. CN XII ANS: C QUIZ: The nurse asks a pt to point a foot towards the ground. What is the term used to describe this type of movement? a. Dorsiflexion b. Supination c. Plantar flexion d. Hyperextension ANS: C QUIZ: The nurse cares for a car accident pt with paralysis of the arms & legs. What is the term used to describe this type of muscle condition? a. Flaccidity b. Paraplegia c. Hemiparesis d. Quadriplegia ANS: D QUIZ: The nurse asks a pt to shrug the shoulders. Which cranial nerve is the nurse testing for? a. CN III b. CN V
-Hyperkalemia -Severe impairment in urine creatinine clearance QUIZ: What is the 1st line for UTIs? ANS: Sulfamethoxazole/Trimethoprim QUIZ: The nurse cares for a patient who has a urinary tract infection (UTI). Which of the following antibiotics is considered first-line treatment? a. Cephalexin. b. Ciprofloxacin. c. Sulfadoxine/Pyrimethamine. d. Sulfamethoxazole/Trimethoprim. ANS: D QUIZ: What is the drug class for Ciprofloxacin? ANS: Fluoroquinolones QUIZ: What is the therapeutic use for Ciprofloxacin? ANS: -Broad spectrum antimicrobial: treats wide variety of micro-organisms gram (+) bacteria & gram (-) bacteria -GI tract infections -Infections of bone/joints, skin & soft tissue -Respiratory infections -UTIs -Prevention of anthrax for pts who have inhaled anthrax sores QUIZ: What are the complications of Ciprofloxacin? ANS: -N/V/D -Dizziness, headaches, confusion -Achilles tendon rupture -Photosensitivity/toxicity from direct/indirect sunlight & sun lamps -Suprainfection: thrush, vaginal yeast infection QUIZ: What are the contraindications of Ciprofloxacin? ANS: -Allergy to fluoroquinlones -Tendon pain -Increased risk for a CDiff infection -Don't administer to kids <18 yrs unless for E. Coli QUIZ: What is the drug class for Nitrofurantoin? ANS: Urinary antiseptic QUIZ: What is the therapeutic use for Nitrofurantoin? ANS: -Acute UTIs -Prophylaxis for recurrent lower UTIs -Not effective in systemic bacterial infections QUIZ: What are the complications of Nitrofurantoin? ANS: -Dizziness, drowsiness, or headaches -N/V/D
-Hypersensitivity reactions: fever, chills, pulmonary manifestations- (alveolar infiltrations, cough, or dyspnea). -Blood cell deficiencies: anemia, macrocytic anemia, thrombocytopenia, neutropenia -Hepatotoxicity -Neuropathy QUIZ: What are the contraindications of Nitrofurantoin? ANS: -Allergy to Nitrofurantoin -Impaired kidney functions (with low urine creatinine clearance levels) -Jaundice from gallbladder disease -Pregnant pts > 38 months -Use cautiously in pts with respiratory disorders, liver disorders, kidney disorder QUIZ: What is hepatotoxicity? ANS: A state of toxic damage to the liver QUIZ: What is peripheral neuropathy? ANS: Numbness/tingling of hands and feet, muscle weakness. QUIZ: What is the nursing consideration for blood dyscrasias (Nitrofurantoin)? ANS: Baseline complete blood count (CBC) & periodically; monitoring for easy bruising and epistaxis QUIZ: What is the nursing consideration for hepatotoxicity (Nitrofurantoin)? ANS: Baseline liver function tests (LFTs) and periodically. QUIZ: What is the nursing consideration for hypersensitivity reaction (Nitrofurantoin)? ANS: STOP medication and report reactions to HCP! QUIZ: What is the nursing consideration for peripheral neuropathy (Nitrofurantoin)? ANS: AVOID in patients with chronic renal insufficiency or chronic kidney disease (CKD) due to increased risk for peripheral neuropathy! QUIZ: What should you give if a pt has respiratory depression? ANS: Naloxone QUIZ: What is stress incontinence? ANS: If u leak urine during activities like coughing, laughing, sneezing, or exercising QUIZ: What is urge incontinence? ANS: If u leak urine after a strong sudden urge to urinate QUIZ: What is mixed incontinence? ANS: Combination of stress and urge incontinence QUIZ: What is temp. incontinence? ANS: U may have an illness like an UTI that causes frequent & sudden urination
QUIZ: What is sexual health? ANS: The integration of the emotional, intellectual, social, and somatic aspects of sexual being, in ways that are positively enriching and that enhance communication, love, and personality. QUIZ: What is gender (biological sex)? ANS: Denotes chromosomal sexual development: XX = female & XY = male. QUIZ: What is gender identity? ANS: The inner sense one has of being male or female, which may be the same or different from biologic gender. QUIZ: What is gender role? ANS: The behavior a person conveys about being male or female. QUIZ: What are factors affecting sexuality? ANS: -Body image & self-concept -Cognition & intellect -Culture & religion -Environment -Ethics -Family beliefs & values -Personal expectations -Previous experiences & relationships QUIZ: In completing an admission history, the nurse learns that the female patient has a female sexual partner. This data speaks to the patient's: a. Gender identity. b. Gender role. c. Sexual bias. d. Sexual orientation. ANS: D QUIZ: Breast tissue and lymph drainage for the breast extend up into the axilla. The majority of breast tumors are found in the ____________________, in the axilla. ANS: Tail of Spence QUIZ: Upon hospital admission, when gathering a patient's sexual history, nurses should: a. Discuss sexual concerns only if the patient raises questions or concerns. b. Focus only on physical factors that affect sexual functioning. c. Include questions related to sexual function. d. Use emotionally laden terms when discussing sexual concepts. ANS: C QUIZ: When is the best time to do a BSE? ANS: Week after period cuz the hormones are at the lowest point, during a period there can be lumps or u can have a lumpy breast
QUIZ: The 17-year-old patient comes to the clinic. She states to the nurse, "I think I have an infection in my vagina." After obtaining information on the signs and symptoms, what is the nurse's best response? a. "Can you tell me what kind of infection you think you have?" b. "Do you know how you got this infection?" c. "Have you told your mother about your concerns?" d. "Let's discuss your current sexual activity." ANS: D QUIZ: True or False: Doing a BSE in the shower is best ANS: True QUIZ: What is the most common age group for a TSE/screening? ANS: 15- QUIZ: ______________________: when a man can't get or keep an erection firm enough for sexual intercourse. ANS: Erectile dysfunction (ED) or impotence QUIZ: BP meds can cause ED, but if a pt stops taking the BP meds what will happen? ANS: They can have a massive stroke QUIZ: ________________ : postmenopausal women have decreased vaginal lubrication, which often results in dyspareunia. ANS: Menopause (end of menses for @ least 12 months, which leads to loss of estrogen) QUIZ: What is dyspareunia? ANS: Painful sexual intercourse QUIZ: _________________________: in women, a group of symptoms (i.e. breast tenderness, headaches, & mood swings) before menses. ANS: Premenstrual symptoms (PMS) QUIZ: _________________________ is a surgery used to treat urinary problems due to an enlarged prostate]. ANS: Transurethral resection of the prostate (TURP) QUIZ: What are the barrier methods of contraception: blocks sperm from entering uterus? ANS: -Cervical cap -Condom -Diaphragm -Spermicides -Vaginal sponge QUIZ: True or False: The calendar method does not work for irregular period ANS: True QUIZ: What is methods is included in tier 1 for most effective contraception? ANS: 1. Sterilization
- Implant
- IUD
