Health Assessment Final (NR 304) Exam Questions with 100% Correct Answers

Hypovolemic shock Correct Answer emergency situation which severe blood or fluid loss makes heart unable pump enough blood to body -can cause organ failure Causes of hypovolemic shock Correct Answer bleeding Burns Diarrhea Excessive perspiration Vomiting Signs & symptoms of hypovolemic shock Correct Answer major blood loss Rapid heartbeat (tachycardia) Quick, shallow breathing Fatigue/weakness Confusion Little - no urine output Low BP Cool, clammy skin Deep vein thrombosis (DVT) Correct Answer blood clot (thrombus) forms in a large vein, usually in a lower limb -if swells = thrombophlebitis Risk factors for DVT Correct Answer prolonged bed-rest Immobility Heart failure Obesity Varicose veins Used to determine severity of DVT Correct Answer wells score -1 to 2: moderate -3+: high Signs & symptoms of DVT Correct Answer aching calf pain/lower leg pain -worse at end of day/prolonged siting or standing Itching w/ stasis dermatits Lower leg edema unresolved w/ diuretic therapy -firm & brawny Coarse, thickened skin Normal pulse Brown pigment discoloration Petichea Venous stasis = increased venous pressure/RBC leakage Expected vital signs of 2 month old infant Correct Answer -reverse order: respirations, pulse then temperature -temperature = rectal *probe no further 1 in. *normally higher than older ages (~100 degrees) -pulse = apical rate *fluctuates more in response to illness & emotions *awake ~100-190 *asleep ~90-160 -respirations = count 1 full minute *more diaphragmatic than thoracic *sleeping rate more accurate *tachypnea = >60/min (indication of infection/fever) *~30-53 breaths/min -BP = electronic device or doppler ultrasound *smaller arm vessels = harder hear korotkoff sounds *~72-104/37-53 Peripheral artery disease (PAD) Correct Answer Common circulatory problem in which narrowed arteries reduce blood flow to limbs -affects non-coronary arteries -blood flow can't match muscle demand during exercise Signs & symptoms of PAD Correct Answer painful cramping after certain activities Leg numbness/weakness Coldness lower leg & foot Shiny skin/no hair on legs No pulse/weak pulse in legs & foot Non-healing sores on toes, feet, leg Change color legs Hair loss/distribution changes Causes of PAD Correct Answer atherosclerosis Risk factors for PAD Correct Answer smoking Diabetes mellitus Kidney disease High BP High cholesterol >50 yrs old Obesity Sedentary lifestyle African American