NUR 265 EXAM FINAL EXAM
QUESTIONS AND ANSWERS 100%
SOLVED
Primary data (2) - ANSWERS- original document
- clinical trials or client interviews
secondary - ANSWERS- document that describes an event, person, place, or thing
First level priority - ANSWERSemergent/life threatening (not breathing)
second level priority - ANSWERSurgent (acute pain, mental status change)
third level priority - ANSWERSneeds attention but not a priority (mobility, rest)
macule - ANSWERSfreckle, mole, measles
patch - ANSWERSbirthmark, hormone change
papule - ANSWERSwart, skin tag
plaque - ANSWERSpsoriasis, eczema
wheal - ANSWERSinsect bite, hives
nodule - ANSWERSmelanoma, hemangioma
tumor - ANSWERSlipoma, neoplasm
vesicle - ANSWERSvaricella, shingles
cyst - ANSWERScystic acne, sebaceous cyst
lichenification - ANSWERSchronic skin inflammation
crust - ANSWERSscab, eczema
scale - ANSWERSpsoriasis, eczema
erosion - ANSWERSvaricella, herpes simplex
, fissure - ANSWERScheilosis
ulcer - ANSWERSpressure injury
excoriation - ANSWERSabrasions
ecchymosis - ANSWERSbruise
ABCDE (5) - ANSWERSasymmetry, border, color, diameter, evolving
stage 1 pressure injury - ANSWERSnon-blanchable erythema of intact skin
stage 2 pressure injury - ANSWERSpartial thickness skin loss with exposed dermis
stage 3 pressure injury - ANSWERSfull thickness loss, looks like deep crater extend to
fascia, subcutaneous tissue damaged/necrotic fat visible
undermining/tunneling may be present damage to surrounding tissue
stage 4 pressure injury - ANSWERSFull thickness skin and tissue loss, exposed fascia,
muscle, tendon, ligament, cartilage, or bone
+1 edema - ANSWERS2mm, rebound immediately
+2 edema - ANSWERS4mm, less than 15 sec
+3 edema - ANSWERSrebounding less than 60 secs
+4 edema - ANSWERS8mm, rebounds 2-3 mins
S1 - ANSWERSclosing of mitral and tricuspid valves, loudest at apex
S2 - ANSWERSclosing of the aortic and pulmonic valves, loudest at base of heart
S3 - ANSWERSnormal in children, adolescents, and pregnancy
S4 - ANSWERSindicates myocardial infarction (MI)
Palpate carotid artery - ANSWERS-Palpate only one carotid artery at a time to avoid
compromising arterial blood to brain.
-Feel contour and amplitude of pulse, normal strength 2+.
-Findings should be same bilaterally
- should feel soft and palpable
assess jugular veins - ANSWERS- inspect in supine position @ 45º angle
- look for fullness and pulsations
QUESTIONS AND ANSWERS 100%
SOLVED
Primary data (2) - ANSWERS- original document
- clinical trials or client interviews
secondary - ANSWERS- document that describes an event, person, place, or thing
First level priority - ANSWERSemergent/life threatening (not breathing)
second level priority - ANSWERSurgent (acute pain, mental status change)
third level priority - ANSWERSneeds attention but not a priority (mobility, rest)
macule - ANSWERSfreckle, mole, measles
patch - ANSWERSbirthmark, hormone change
papule - ANSWERSwart, skin tag
plaque - ANSWERSpsoriasis, eczema
wheal - ANSWERSinsect bite, hives
nodule - ANSWERSmelanoma, hemangioma
tumor - ANSWERSlipoma, neoplasm
vesicle - ANSWERSvaricella, shingles
cyst - ANSWERScystic acne, sebaceous cyst
lichenification - ANSWERSchronic skin inflammation
crust - ANSWERSscab, eczema
scale - ANSWERSpsoriasis, eczema
erosion - ANSWERSvaricella, herpes simplex
, fissure - ANSWERScheilosis
ulcer - ANSWERSpressure injury
excoriation - ANSWERSabrasions
ecchymosis - ANSWERSbruise
ABCDE (5) - ANSWERSasymmetry, border, color, diameter, evolving
stage 1 pressure injury - ANSWERSnon-blanchable erythema of intact skin
stage 2 pressure injury - ANSWERSpartial thickness skin loss with exposed dermis
stage 3 pressure injury - ANSWERSfull thickness loss, looks like deep crater extend to
fascia, subcutaneous tissue damaged/necrotic fat visible
undermining/tunneling may be present damage to surrounding tissue
stage 4 pressure injury - ANSWERSFull thickness skin and tissue loss, exposed fascia,
muscle, tendon, ligament, cartilage, or bone
+1 edema - ANSWERS2mm, rebound immediately
+2 edema - ANSWERS4mm, less than 15 sec
+3 edema - ANSWERSrebounding less than 60 secs
+4 edema - ANSWERS8mm, rebounds 2-3 mins
S1 - ANSWERSclosing of mitral and tricuspid valves, loudest at apex
S2 - ANSWERSclosing of the aortic and pulmonic valves, loudest at base of heart
S3 - ANSWERSnormal in children, adolescents, and pregnancy
S4 - ANSWERSindicates myocardial infarction (MI)
Palpate carotid artery - ANSWERS-Palpate only one carotid artery at a time to avoid
compromising arterial blood to brain.
-Feel contour and amplitude of pulse, normal strength 2+.
-Findings should be same bilaterally
- should feel soft and palpable
assess jugular veins - ANSWERS- inspect in supine position @ 45º angle
- look for fullness and pulsations
