NUR 2830 Final Exam Updated 2024/2025 Actual Questions and answers with complete solutions

+1 slight pitting edema - 2mm depression +2 increased pitting edema - 4mm depression +3 deeper pitting edema - 6mm; obvious edema of extremity +4 severe pitting edema - 8mm depression, extremity appears very edematous 0/5 strength - total paralysis 1/5 strength - muscle contraction is noted but no movement occurs 2/5 strength - some movement but insufficient to counteract gravity, cannot perform ROM against gravity 3/5 strength - contract your muscle and move your body part through its full range of motion against the force of gravity, when resistance is applied, the muscle is unable to maintain the contraction 4/5 strength - the muscle is able to contract and provide some resistance 5/5 strength - muscle is functioning normally and is able to maintain its position 6 P's - -pain -pallor -poikilothermia-paresthesis -pulselessness -paralysis 7 step process - identify abnormals, cluster data, draw inferences, nursing diagnosis, check for presence of defining characteristics, confirm or rule out diagnosis, document abdomen - inspect, auscultate, palpate, percuss abduction - away from the body Abnormal abdominal findings - -dysphagia: difficulty swallowing -polyuria: frequent urination -nocturia: waking up at night to pee -dysuria: painful urination -jaundice: yellowing of skin, associated with liver -friction rub: what sounds heard with peritilis- pleural friction rub -flank pain: related to kidney Acute Pain - identifiable cause such as trauma, results from damaged tissues adduction - add to body Albumin - prime ingredient of blood oncotic pressure and a carrier protein for many body and pharmacological substances arterial system - consists of arteries, arterioles and capillaries hat deliver oxygenated blood from the heart to the rest of the bodyarterial ulcers - located in the toes, metatarsals, malleoli, and heels. The borders are regular. Ulcer base is pale, yellow and there is minimal drainage. It is painful, decreased with dependency. The skin is pale, inflamed, and necrotic. The pulses are decreased or absent. Gangrene may be present. defined edges, ISCHEMIA! Ascites - fluid in abdomen, everted umbilical. results from cirrhosis of the liver asthma - person's airways become inflamed, narrow and swell, and produce extra Basal cell - least risky type of cancer, nodule solid, palpable, less than 1cm, shiny with rolled pearly border Blood Pressure - 120/80, 130 prehypertension, 140 hyertension, 90 hypotension. Emergency: 100/70 Blumberg sign/rebound tenderness - to check for peritonitis Braden Scale - pressure sore risk assessment: the higher the number the least impact your patient is, lower the number the higher the risk. need to assess PT in between every shift breast - inspect and palpate