NMNC 3210 FINAL EXAM QUESTIONS & ANSWERS
T/F
abnormal immune response is either exaggerated or suppressed - Answers - TRUE
visual field - Answers - part of space that can be seen when head & eyes are
motionless
retinal damage - Answers - Hypertension complication
Appearance of retina provides important info about severity and duration of
hypertension
damaged retinal vessels provide indication of concurrent vessel damage in the heart,
brain, kidneys
ocular pressure - Answers - pressure inside the eye, may be elevated in pts with
glaucoma
visual acuity - Answers - ability to see fine detail
sharpness of vision
How does the CDC classify BMI categories? - Answers - <18.5 - underweight
18.5-24.9 - healthy weight
25-29.9 - overweight
30+ - obese
What is protein calorie malnutrition? - Answers - severe wasting of muscle and fat as
the person is starved for total food or energy
starvation-related malnutrition (primary problem) - nutritional needs for calories /
proteins not met
Why is folic acid important during pregnancy? When should women take it? - Answers
- it prevents neural tube defects
women should start taking it before trying to get pregnant
How does Rh Immunoglobulin work? When should it be administered? Who would it be
prescribed for and why? - Answers - Administer Rh immunoglobulin IM to Rh- mother
w Rh+ infant
What are the stages and phases of labor? - Answers - Stage 1 - contractions & cervix
opens
,- latent phase
- active phase
- transition phase
Stage 2 - birth of baby
Stage 3 - birth of placenta
Stage 4 - recovery
What are the most important assessments during labor? For the mom? For the baby? -
Answers - Duration - how long (time from beginning of one contraction to the end)
Intensity - how strong (can she talk, does walking make it better, does mild sedation
relieve pain)
Frequency - how often (time from beginning of one contraction to beginning of another)
Fetal monitoring system & auscultation
Fetal position & fetal station
What are the most important assessments in the first 24 hours after birth? - Answers -
BABY
first meconium stool after 24hr
Weight - 6-8lbs (2500-4000g)
Length - 18-22" (45-55cm)
Head circumference - 13-14" (32-37cm)
Chest circumference - (compare to head)(Abdominal circumference prn)
Apgar
VS
- HR - 120-160bpm
- BP - 60-80/40-50
- TEMP - 97.6-99.6F (36.5-37.5C)
- RR - 30-60 breaths/min
- O2 - 95%
MAMA - BUBBLE
Breasts
Uterus
Bowel
Bladder
Lochia
Episiotomy/laceration/C-section incision
What is an APGAR test? When is it performed? What does it indicate? - Answers -
total score of 7-10 = adaptation
what is maternal-infant bonding? - Answers - - feeding
- eye contact
- sucking/rooting reflexes
- attachment
,- EBP shows best time to promote bonding is immediately after birth via placing baby
skin to skin on mothers chest
How is cataract removal surgery done? - Answers - Perioperative
- H&P - most pt older adults c multiple health problems
- Nonsteroidal anti-inflammatory eye drop
- Dilation eye drop (mydriatic)
- Cycloplegic (tropicamide) - paralyzes accommodation & iris sphincter muscle
- Antianxiety meds
Intraoperative
- Phacoemulsification - most common cataract surg
· Small incision made on surface of eye near cornea
· Thin ultrasound probe inserted & ultrasonic vibrations used to break up clouded lens &
suctioned out
· Self-healing incision
- Extracapsular cataract extraction procedure
· Advanced cataracts, large incision requiring sutures
· Extracted in one piece
· IOL (intraocular lens) placed at time of cataract extraction surgery
· Longer recovery time
Postoperative
- Ready for discharge after sedative has worn off
- Meds
· Antibiotic drops
· Corticosteroid drops
· Drop freq will decrease & stop when eye heals
- AVOID activities that increase IOP
- Postop exams - visual acuity, anterior chamber depth, corneal clarity, IOP
What are some nursing interventions for a person who is blind? - Answers - - keep bed
in low position
- keep personal items within reach
- be especially diligent and descriptive in communicating before touching pt
What is tinnitus? - Answers - ringing or clicking sound in the ears in the absence of
auditory stimuli
caused by cerumen occlusion, meds, acoustic neuroma, Ménière's disease, high BP,
noise exposure, head/ear/neck trauma, head/neck illness, drugs, stress
How can you improve communication with someone who is hearing impaired? -
Answers - - Assistive devices
- Sign language
- Closed caption
, - Assistive listening
- Well lit room
- Eye contact
- Normal pace speech
How does the body regulate temperature? - Answers - heat production & loss
when body temp is up, dermal blood vessels dilate & sweat glands secrete sweat
when body temperature is down, dermal blood vessels constrict & sweat glands
become inactive
during excessive heat loss, skeletal muscles are stimulated to contract individually
What are some mechanisms by which the body loses heat? - Answers - × Convection -
stood in cold wind
× Evaporation - got out of a cold lake
× Conduction - sat on a cold rock
× Radiation - walked in the cold air
Who is at risk for alterations in thermoregulation? - Answers - Populations at Risk
- Neonates - higher BSA, less subcutaneous fat, and decreased sweating/shivering
- Older Adults - slower circulation/constriction, decreased sweating/shivering and heat
prod, reduced perception of environmental temp
- Socioeconomic - lack of resources, homeless
- Demographic - males & African American
- Recreational/occupational exposures
Individuals at risk
- Impaired cognition (disorders/substances) - unable to know when to seek out changes
- Impaired mobility - unable to get fluids, put on/remove clothing, change environment
- Underlying health conditions - fluid deficits
- Genetics - malignant hyperthermia
- Use of alcohol/certain meds
What is the best way to assess core temperature? - Answers - rectal temperature
What interventions should be prioritized for treating hypothermia? - Answers - warm up
monitor cardiac fxn closely
What is important to remember about cardiac function during hypothermia? What about
when performing CPR on a patient with hypothermia? - Answers - × Clotting
abnormalities & thrombocytopenia
- Procedures may cause hemorrhage
× Cardiac dysrhythmias - cold irritates the heart
- ECG - prolonged conduction times
T/F
abnormal immune response is either exaggerated or suppressed - Answers - TRUE
visual field - Answers - part of space that can be seen when head & eyes are
motionless
retinal damage - Answers - Hypertension complication
Appearance of retina provides important info about severity and duration of
hypertension
damaged retinal vessels provide indication of concurrent vessel damage in the heart,
brain, kidneys
ocular pressure - Answers - pressure inside the eye, may be elevated in pts with
glaucoma
visual acuity - Answers - ability to see fine detail
sharpness of vision
How does the CDC classify BMI categories? - Answers - <18.5 - underweight
18.5-24.9 - healthy weight
25-29.9 - overweight
30+ - obese
What is protein calorie malnutrition? - Answers - severe wasting of muscle and fat as
the person is starved for total food or energy
starvation-related malnutrition (primary problem) - nutritional needs for calories /
proteins not met
Why is folic acid important during pregnancy? When should women take it? - Answers
- it prevents neural tube defects
women should start taking it before trying to get pregnant
How does Rh Immunoglobulin work? When should it be administered? Who would it be
prescribed for and why? - Answers - Administer Rh immunoglobulin IM to Rh- mother
w Rh+ infant
What are the stages and phases of labor? - Answers - Stage 1 - contractions & cervix
opens
,- latent phase
- active phase
- transition phase
Stage 2 - birth of baby
Stage 3 - birth of placenta
Stage 4 - recovery
What are the most important assessments during labor? For the mom? For the baby? -
Answers - Duration - how long (time from beginning of one contraction to the end)
Intensity - how strong (can she talk, does walking make it better, does mild sedation
relieve pain)
Frequency - how often (time from beginning of one contraction to beginning of another)
Fetal monitoring system & auscultation
Fetal position & fetal station
What are the most important assessments in the first 24 hours after birth? - Answers -
BABY
first meconium stool after 24hr
Weight - 6-8lbs (2500-4000g)
Length - 18-22" (45-55cm)
Head circumference - 13-14" (32-37cm)
Chest circumference - (compare to head)(Abdominal circumference prn)
Apgar
VS
- HR - 120-160bpm
- BP - 60-80/40-50
- TEMP - 97.6-99.6F (36.5-37.5C)
- RR - 30-60 breaths/min
- O2 - 95%
MAMA - BUBBLE
Breasts
Uterus
Bowel
Bladder
Lochia
Episiotomy/laceration/C-section incision
What is an APGAR test? When is it performed? What does it indicate? - Answers -
total score of 7-10 = adaptation
what is maternal-infant bonding? - Answers - - feeding
- eye contact
- sucking/rooting reflexes
- attachment
,- EBP shows best time to promote bonding is immediately after birth via placing baby
skin to skin on mothers chest
How is cataract removal surgery done? - Answers - Perioperative
- H&P - most pt older adults c multiple health problems
- Nonsteroidal anti-inflammatory eye drop
- Dilation eye drop (mydriatic)
- Cycloplegic (tropicamide) - paralyzes accommodation & iris sphincter muscle
- Antianxiety meds
Intraoperative
- Phacoemulsification - most common cataract surg
· Small incision made on surface of eye near cornea
· Thin ultrasound probe inserted & ultrasonic vibrations used to break up clouded lens &
suctioned out
· Self-healing incision
- Extracapsular cataract extraction procedure
· Advanced cataracts, large incision requiring sutures
· Extracted in one piece
· IOL (intraocular lens) placed at time of cataract extraction surgery
· Longer recovery time
Postoperative
- Ready for discharge after sedative has worn off
- Meds
· Antibiotic drops
· Corticosteroid drops
· Drop freq will decrease & stop when eye heals
- AVOID activities that increase IOP
- Postop exams - visual acuity, anterior chamber depth, corneal clarity, IOP
What are some nursing interventions for a person who is blind? - Answers - - keep bed
in low position
- keep personal items within reach
- be especially diligent and descriptive in communicating before touching pt
What is tinnitus? - Answers - ringing or clicking sound in the ears in the absence of
auditory stimuli
caused by cerumen occlusion, meds, acoustic neuroma, Ménière's disease, high BP,
noise exposure, head/ear/neck trauma, head/neck illness, drugs, stress
How can you improve communication with someone who is hearing impaired? -
Answers - - Assistive devices
- Sign language
- Closed caption
, - Assistive listening
- Well lit room
- Eye contact
- Normal pace speech
How does the body regulate temperature? - Answers - heat production & loss
when body temp is up, dermal blood vessels dilate & sweat glands secrete sweat
when body temperature is down, dermal blood vessels constrict & sweat glands
become inactive
during excessive heat loss, skeletal muscles are stimulated to contract individually
What are some mechanisms by which the body loses heat? - Answers - × Convection -
stood in cold wind
× Evaporation - got out of a cold lake
× Conduction - sat on a cold rock
× Radiation - walked in the cold air
Who is at risk for alterations in thermoregulation? - Answers - Populations at Risk
- Neonates - higher BSA, less subcutaneous fat, and decreased sweating/shivering
- Older Adults - slower circulation/constriction, decreased sweating/shivering and heat
prod, reduced perception of environmental temp
- Socioeconomic - lack of resources, homeless
- Demographic - males & African American
- Recreational/occupational exposures
Individuals at risk
- Impaired cognition (disorders/substances) - unable to know when to seek out changes
- Impaired mobility - unable to get fluids, put on/remove clothing, change environment
- Underlying health conditions - fluid deficits
- Genetics - malignant hyperthermia
- Use of alcohol/certain meds
What is the best way to assess core temperature? - Answers - rectal temperature
What interventions should be prioritized for treating hypothermia? - Answers - warm up
monitor cardiac fxn closely
What is important to remember about cardiac function during hypothermia? What about
when performing CPR on a patient with hypothermia? - Answers - × Clotting
abnormalities & thrombocytopenia
- Procedures may cause hemorrhage
× Cardiac dysrhythmias - cold irritates the heart
- ECG - prolonged conduction times
