NURS 175 FINAL EXAM QUESTIONS AND VERIFIED
ANSWERS
Orthostatic BP is? - Answers - difference of >20 systolic and/or >10 diastolic
Apical pulse location - Answers - Mid clavicular line, 5th intercostal space
4 broad aims of nursing practice - Answers - 1. To promote health
2. To prevent illness
3. To restore health
4. To facilitate coping with disability or death
Maslow's Hierarchy of Needs - Answers - (level 1) Physiological Needs
(level 2) Safety and Security
(level 3) Relationships, Love and Affection
(level 4) Self Esteem
(level 5) Self Actualization
Hans Selye's - General Adaptation Syndrome - Answers - (ARE)
Alarm Reaction - fight or flight, increase energy, increase O2, increase CO, increase
BP, increase alertness
Stage of Resistance - neuro activity returns to normal, LAS
Stage of Exhaustion - decrease BP, decrease HR, decrease resp, PANIC
Transmission precautions - Answers - Airborne, Droplet, Contact
Chain of infection: - Answers - infectious agent > reservoir > portal of exit > mode of
transmission > portal of entry > susceptible host
Aseptic vs Sterile - Answers - aseptic=clean
sterile=surgery
Signs & symptoms of Infection - Answers - - redness
- fever
- inflammation
- swelling
Delegation - Answers - UAP's can not "assess, teach or educate"
Comprehensive assessment - Answers - health history and complete physical
examination, usually conducted when a patient FIRST enters a health care setting;
provides a BASELINE for comparing later assessment
, Focused assessment - Answers - assessment conducted to assess a specific problem;
focuses on pertinent history and body regions
Ongoing (time-lapsed) assessment - Answers - continuing assessment activities that
proceed from the initial nursing assessment
ADPIE - Nursing Process - Answers - Assessment
Diagnosis
Planning
Implementation
Evaluation
Patient centered goals: SMART - Answers - Specific
Measurable
Attainable
Realistic
Timed
What are the ABC's? - Answers - Airway, Breathing, Circulation
SBAR stands for? - Answers - Situation
Background
Assessment
Recommendation
Hemiparesis means - Answers - weakness on one side
Hemiplegia means - Answers - paralysis of one side of the body
Benefits of activity - Answers - improved CV and respiratory health;
improved strength and mobility;
maintenance of bone density;
maintenance of healthy weight and metabolism;
improved psycho social health
Improved elimination
healthy skin
Effects of Immobility - Answers - Muscle atrophy
Joint dysfunction
Atelectasis/pneumonia
Venous stasis
Increased coagulability
Orthostatic hypotension
Decrease skin integrity
Decrease appetite
ANSWERS
Orthostatic BP is? - Answers - difference of >20 systolic and/or >10 diastolic
Apical pulse location - Answers - Mid clavicular line, 5th intercostal space
4 broad aims of nursing practice - Answers - 1. To promote health
2. To prevent illness
3. To restore health
4. To facilitate coping with disability or death
Maslow's Hierarchy of Needs - Answers - (level 1) Physiological Needs
(level 2) Safety and Security
(level 3) Relationships, Love and Affection
(level 4) Self Esteem
(level 5) Self Actualization
Hans Selye's - General Adaptation Syndrome - Answers - (ARE)
Alarm Reaction - fight or flight, increase energy, increase O2, increase CO, increase
BP, increase alertness
Stage of Resistance - neuro activity returns to normal, LAS
Stage of Exhaustion - decrease BP, decrease HR, decrease resp, PANIC
Transmission precautions - Answers - Airborne, Droplet, Contact
Chain of infection: - Answers - infectious agent > reservoir > portal of exit > mode of
transmission > portal of entry > susceptible host
Aseptic vs Sterile - Answers - aseptic=clean
sterile=surgery
Signs & symptoms of Infection - Answers - - redness
- fever
- inflammation
- swelling
Delegation - Answers - UAP's can not "assess, teach or educate"
Comprehensive assessment - Answers - health history and complete physical
examination, usually conducted when a patient FIRST enters a health care setting;
provides a BASELINE for comparing later assessment
, Focused assessment - Answers - assessment conducted to assess a specific problem;
focuses on pertinent history and body regions
Ongoing (time-lapsed) assessment - Answers - continuing assessment activities that
proceed from the initial nursing assessment
ADPIE - Nursing Process - Answers - Assessment
Diagnosis
Planning
Implementation
Evaluation
Patient centered goals: SMART - Answers - Specific
Measurable
Attainable
Realistic
Timed
What are the ABC's? - Answers - Airway, Breathing, Circulation
SBAR stands for? - Answers - Situation
Background
Assessment
Recommendation
Hemiparesis means - Answers - weakness on one side
Hemiplegia means - Answers - paralysis of one side of the body
Benefits of activity - Answers - improved CV and respiratory health;
improved strength and mobility;
maintenance of bone density;
maintenance of healthy weight and metabolism;
improved psycho social health
Improved elimination
healthy skin
Effects of Immobility - Answers - Muscle atrophy
Joint dysfunction
Atelectasis/pneumonia
Venous stasis
Increased coagulability
Orthostatic hypotension
Decrease skin integrity
Decrease appetite
