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Exam (elaborations)

NUR 382 EXAM 1 QUESTIONS WITH COMPLETE ANSWERS

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NUR 382 EXAM 1 QUESTIONS WITH COMPLETE ANSWERS

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Palpate point of maximal impulse


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Patient should be supine- Hand

PMI is also called apical area. located between the 5 & 6 intercostal space
-Have the patient lay flat, with the palm of hand palpating the Apex, left
sternal border, and the base feeling for pulsations
-Normal-single outward impulse (contraction of the Left ventricle)
-Abnormal- double impulse, Left lateral displacement, Heaves, Lifts




auscultate apical pulse


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, -rate and rhythm
-upper portion of heart= base
-lower portion of heart =apex
-PMI= point of maximal impulse is the apex
-5th ICS at midclavicular line




Pulmonary Assessment


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Auscultate the chest - breath sounds should be present and equal
Listen to the cry - evaluate for obstruction or narrowing of the airway
Work of breathing- grunting, flaring, retractions




The interview process


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-Check personal issues and bias at the door
-Provide privacy and non-distracting environment
-Introductions
-Name, Title, Permission
-Patient Identifiers
-Name, DOB, MRN, address, photo
-Patient may remain clothed
-Sit or stand at the same level
-Assess sensory deficits/ learning deficits
-Use open-ended and clarify with close-ended questions
-Be empathetic
-Provide education at every opportunity
-What is the purpose of obtaining a health history?
-Collect subjective information
-Clarification
-Documentation
-Education (Health Promotion is preventative)

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