NUR 216 CORE EXAM MANUAL QUESTIONS AND ANSWERS
MARKED A+
✔✔stage 2 pressure ulcer - ✔✔partial thickness loss of skin
skin breakdown of the epidermis and dermis
red/pink, shiny wound bed
✔✔stage 3 pressure ulcer: - ✔✔-full thickness skin loss
drainage or necrosis tissue, subcutaneous fat may be visible
-dead tissue may be present in wound bed
-deep without exposed muscle or bone
✔✔stage 4 pressure ulcer - ✔✔-Full-thickness skin and tissue loss with exposed bone,
muscle, or tendon
-tissue necrosis or damage to muscle, bone or underlying structures
-slough, eschar, tunneling, undermining
(osteomyelitis bone infection)
✔✔unstageable - ✔✔ulcer is covered with slough or eschar
depth unknown
✔✔deep tissue injury DTI - ✔✔discoloration but skin is INTACT
damage to underlying tissue
appears as a bruise with intact skin
deeper discoloration
✔✔Pressure injury management pearls - ✔✔S: surface should be smooth
K: keep moving
I: incontinence management
N: nutrition (protein)
✔✔pressure injury nursing interventions: - ✔✔-lift device
-specialty mattress
-assess every 8 hours or per shift: braden scale
-clean skin with warm water and little friction
-moisture barrier cream
-nutrient dense foods: high protein diet
-provide wound care per facility guidelines
-prevention is key!!
-inspect everyday
-ensure linens are clean and wrinkle free
-reposition q2hrs or more, shift weight q15mins (chair)
-limit chair time to 1 hour
- keeping head less than 30 degrees
-float heels
,-ambulate - ROM
✔✔hair care - ✔✔color and texture
- due to melanin productions
-thick to fine
-distribution (TANNER staging, pubic region)
-evenly distributed
-unexpected findings: lack of hair on legs - possible vascular disease: alopecia
-lesions and infestations identify by looking at scalp and dividing hair into sections
WEAR GLOVES
✔✔nails: - ✔✔shape and contour
-expected: slightly curved or flat smooth, uniform thickness, nail bed should be color of
skin tone
-unexpected: cyanosis, pallor, clubbing of nails(160 degrees), jagged nails
capillary refill
-push down on nial bed and count until pink again <3 seconds
-color return usually instant
-indicated status of peripheral circulation)
✔✔expected changes w aging - ✔✔skin is thin and translucent, drier, tears easily, loss
of elasticity and increased wrinkling, leathery appearance.
thinning of hair, hair loss on the scalp or pubic area
slow growth of nails with thickening (decreased circulation)
decline in glandular structure and function (less oil, moisture, and sweat)
uneven pigmentation
slow wound healing
little subcutaneous tissue over bony prominences
increased presence of vitiligo, possibly from autoimmune diseases
lotion as much as possible
✔✔12 cranial nerves nemonic - ✔✔oh: olfactory nerve-sense of smell
oh: optic nerve- ability to see
oh: oculomotor nerve-ability to move and blink your eye
to: trochlear nerve-ability to move your eyes.
tickle: trigeminal nerve- sensations in your face and cheeks tastes and jaw movement
a: abducens nerve: ability to move your eyes
females: facial nerve- facial expressions and sense of taste.
vagina:vestibular nerve- sense of hearing and balance
gave: glossopharyngeal nerve-ability to taste and swallow
victor: vagus nerve-digestion and heart rate
a: accessory nerve-shoulder and neck muscle movement
hard-on: hypoglossal-ability to move your tongue
✔✔tools for HEENT assessment - ✔✔penlight
, otoscope
ophthalmoscope
tongue blade
stethoscope(diaphragm and bell)
cup of water
gloves
snellen chart
2 types of scents
✔✔cranial bones - ✔✔frontal, parietal, temporal, occipital
✔✔head neck and throat subjective data: what the patients tells you - ✔✔head pain/
headaches
jaw tightness/pain
neck pain/stiffness
neck mass
nasal congestion
epistaxis(nose bleed)
mouth lesions or mouth/dental
sore throat
hoarseness
✔✔head/skull - ✔✔inspect first
palpate next
-note size, shape, symmetry and position
-gently rotate fingertips down the center of the scalp
-expected findings: normal cephalic, erect, midline; no lesions or edema present.
-unexpected findings: acromegaly(over growth of bone), deformities, masses,
tenderness; patchy hair loss (autoimmune disorder)
✔✔assessment neck - ✔✔inspect, palpate and auscultation
positions:
-flexion, extension, hyperextension, lateral fixion
ability to swallow
expected findings: trachea is midline; overall color is even; able to swallow secretions
and fluids without difficulty or choking
unexpected findings: stiff neck, lump or mass, stridor(sound is high pitch with breathing)
, difficulty swallowing or visible lymph nodes
✔✔thyroid gland assessment - ✔✔use anterior and posterior approach
locate the isthmus below the carotid cartilage-lower half of the neck
-note size, shape and consistency, tenderness and nodules
-normal size is not visible (hyperextend to better visualize)
-palpate when the client swallows to feel it move up with the trachea (look for size,
smoothness or masses)
-if enlarged auscultate the thyroid for a bruit (bell: whooshing, blowing
MARKED A+
✔✔stage 2 pressure ulcer - ✔✔partial thickness loss of skin
skin breakdown of the epidermis and dermis
red/pink, shiny wound bed
✔✔stage 3 pressure ulcer: - ✔✔-full thickness skin loss
drainage or necrosis tissue, subcutaneous fat may be visible
-dead tissue may be present in wound bed
-deep without exposed muscle or bone
✔✔stage 4 pressure ulcer - ✔✔-Full-thickness skin and tissue loss with exposed bone,
muscle, or tendon
-tissue necrosis or damage to muscle, bone or underlying structures
-slough, eschar, tunneling, undermining
(osteomyelitis bone infection)
✔✔unstageable - ✔✔ulcer is covered with slough or eschar
depth unknown
✔✔deep tissue injury DTI - ✔✔discoloration but skin is INTACT
damage to underlying tissue
appears as a bruise with intact skin
deeper discoloration
✔✔Pressure injury management pearls - ✔✔S: surface should be smooth
K: keep moving
I: incontinence management
N: nutrition (protein)
✔✔pressure injury nursing interventions: - ✔✔-lift device
-specialty mattress
-assess every 8 hours or per shift: braden scale
-clean skin with warm water and little friction
-moisture barrier cream
-nutrient dense foods: high protein diet
-provide wound care per facility guidelines
-prevention is key!!
-inspect everyday
-ensure linens are clean and wrinkle free
-reposition q2hrs or more, shift weight q15mins (chair)
-limit chair time to 1 hour
- keeping head less than 30 degrees
-float heels
,-ambulate - ROM
✔✔hair care - ✔✔color and texture
- due to melanin productions
-thick to fine
-distribution (TANNER staging, pubic region)
-evenly distributed
-unexpected findings: lack of hair on legs - possible vascular disease: alopecia
-lesions and infestations identify by looking at scalp and dividing hair into sections
WEAR GLOVES
✔✔nails: - ✔✔shape and contour
-expected: slightly curved or flat smooth, uniform thickness, nail bed should be color of
skin tone
-unexpected: cyanosis, pallor, clubbing of nails(160 degrees), jagged nails
capillary refill
-push down on nial bed and count until pink again <3 seconds
-color return usually instant
-indicated status of peripheral circulation)
✔✔expected changes w aging - ✔✔skin is thin and translucent, drier, tears easily, loss
of elasticity and increased wrinkling, leathery appearance.
thinning of hair, hair loss on the scalp or pubic area
slow growth of nails with thickening (decreased circulation)
decline in glandular structure and function (less oil, moisture, and sweat)
uneven pigmentation
slow wound healing
little subcutaneous tissue over bony prominences
increased presence of vitiligo, possibly from autoimmune diseases
lotion as much as possible
✔✔12 cranial nerves nemonic - ✔✔oh: olfactory nerve-sense of smell
oh: optic nerve- ability to see
oh: oculomotor nerve-ability to move and blink your eye
to: trochlear nerve-ability to move your eyes.
tickle: trigeminal nerve- sensations in your face and cheeks tastes and jaw movement
a: abducens nerve: ability to move your eyes
females: facial nerve- facial expressions and sense of taste.
vagina:vestibular nerve- sense of hearing and balance
gave: glossopharyngeal nerve-ability to taste and swallow
victor: vagus nerve-digestion and heart rate
a: accessory nerve-shoulder and neck muscle movement
hard-on: hypoglossal-ability to move your tongue
✔✔tools for HEENT assessment - ✔✔penlight
, otoscope
ophthalmoscope
tongue blade
stethoscope(diaphragm and bell)
cup of water
gloves
snellen chart
2 types of scents
✔✔cranial bones - ✔✔frontal, parietal, temporal, occipital
✔✔head neck and throat subjective data: what the patients tells you - ✔✔head pain/
headaches
jaw tightness/pain
neck pain/stiffness
neck mass
nasal congestion
epistaxis(nose bleed)
mouth lesions or mouth/dental
sore throat
hoarseness
✔✔head/skull - ✔✔inspect first
palpate next
-note size, shape, symmetry and position
-gently rotate fingertips down the center of the scalp
-expected findings: normal cephalic, erect, midline; no lesions or edema present.
-unexpected findings: acromegaly(over growth of bone), deformities, masses,
tenderness; patchy hair loss (autoimmune disorder)
✔✔assessment neck - ✔✔inspect, palpate and auscultation
positions:
-flexion, extension, hyperextension, lateral fixion
ability to swallow
expected findings: trachea is midline; overall color is even; able to swallow secretions
and fluids without difficulty or choking
unexpected findings: stiff neck, lump or mass, stridor(sound is high pitch with breathing)
, difficulty swallowing or visible lymph nodes
✔✔thyroid gland assessment - ✔✔use anterior and posterior approach
locate the isthmus below the carotid cartilage-lower half of the neck
-note size, shape and consistency, tenderness and nodules
-normal size is not visible (hyperextend to better visualize)
-palpate when the client swallows to feel it move up with the trachea (look for size,
smoothness or masses)
-if enlarged auscultate the thyroid for a bruit (bell: whooshing, blowing
