NURSING FINAL EXAM
How can you estimate a client's tidal volume? - (correct Answer) - Tidal volume can be estimated by
observing the depth of the client's respirations.
What is the range of normal for an adult's respiratory rate? - (correct Answer) - A rate of 12 to 20 breaths
per minute is normal for adults
Besides the rate, what other characteristics of a client's respirations should you observe? - (correct
Answer) - Depth, rhythm, effort, breath sounds, and chest movement should be observed in addition to
rate.
What are some common clinical signs associated with poor oxygenation? - (correct Answer) - Pallor or
cyanosis of the nails, lips, or skin; restlessness; apprehension; confusion; dizziness; fatigue; changes in
pulse and blood pressure; and decreased level of consciousness are associated with poor oxygenation.
Which of the Korotkoff sounds would you record as the systolic pressure? - (correct Answer) - First
Which of the Korotkoff sounds would you record as the diastolic pressure? - (correct Answer) - Fifth
A nurse is auscultating a BP. He hears the first sound at 170 mm Hg. The sound disappears immediately.
At 150 mm Hg, the sound appears again and continues until there is silence at 80 mm Hg. The pressures
were taken in the client's right arm while the client was lying down.
How should the nurse record these pressures? - (correct Answer) - BP RA, supine, 170/80 with an
auscultatory gap from 170 to 150
How do you explain what happened? - (correct Answer) - An auscultatory gap occurred. A gap is most
commonly heard in hypertensive clients, whose systolic blood pressure is higher than the adult normal
limit of 140 mm Hg.
Which of the following patients has hypertension? One with a BP of:
150/80 on two separate occasions
180/100 on one occasion
138/88 on two occasions - (correct Answer) - 150/80 on two separate occasions
Which of the following client(s) has/have primary hypertension?
Client A, who is obese and has a high sodium intake
Client B, who is in renal failure
Client C, who has hypertension induced by pregnancy
,Client D, who has a family history of hypertension - (correct Answer) - Client D, who has a family history
of hypertension
What are five functions of the skin? - (correct Answer) - The skin serves five functions: protection,
sensation, temperature regulation, secretion/excretion, and formation of vitamin D.
How does the skin help regulate body temperature? - (correct Answer) - The skin contains sensory
organs or receptors for heat and cold. The skin regulates temperature through the process of dilating
and constricting blood vessels and activating or inactivating sweat glands. The sweat glands found in the
axillae and external genitalia secrete fatty acids and proteins and excrete perspiration, which produces a
cooling effect as the moisture evaporates from the skin.
What changes take place in the skin as a person ages - (correct Answer) - With age, both layers of the
skin become thinner and more fragile. As collagen and elastin fibers in the dermis deteriorate, the skin
becomes wrinkled. Sebaceous and sweat gland activity decreases, causing the skin to become dry, scaly,
and itchy, and temperature regulation in hot weather becomes more difficult. As the number and activity
of hair follicles and pigment cells (melanocytes) diminishes, hair becomes thin, turns gray or white, and
grows more slowly. Nails thicken and growth decreases. These changes increase the risk for skin
problems.
True or false: The professional nurse is responsible for making assessments. - (correct Answer) - True
True or false: Assisting with the bath is an excellent time to assess the patient. - (correct Answer) - True
To inspect for pallor in a dark-skinned person, which areas would you assess for an ashen gray or yellow
color? - (correct Answer) - For dark-skinned persons, the conjunctivae, buccal mucosa, tongue, lips, nail
beds, palms, and soles should be assessed for pallor.
What is the term that means "a bluish color of the skin"? - (correct Answer) - Cyanosis means a bluish
discoloration of the skin.
Name two causes of erythema. - (correct Answer) - Vasodilation and inflammation are causes of
erythema.
Where can you best see jaundice? - (correct Answer) - The sclera of the eyes is the best place to see
jaundice
True or false: Healthy nails are usually clean, smooth, and convexly curved - (correct Answer) - True
List at least three nail changes that occur with aging. - (correct Answer) - As a person ages, the nails
thicken, become ridged, and may yellow or become concave in shape.
List at least four things you should teach clients about self-care of their nails. - (correct Answer) -
Answer:
Clients should be taught the following self-care of their nails:
● Inspect the nails daily.
● Trim nails with a nail clipper (people with diabetes or circulatory problems should file only, as cutting
poses a risk for injury to the tissues).
, ● File the nails straight across, rounding the corners slightly to prevent scratching; do not cut deeply into
the lateral corners, as this may cause ingrown nails.
● Remove hangnails by carefully cutting them off.
● Clean under the nails with an orangewood stick or other blunt instrument.
● Push back the cuticles gently.
● Use a moisturizing lotion to soften cuticles.
● Avoid biting nails.
● Consult a podiatrist for any ingrown toenails or other nail problems.
● Recommend to patients with diabetes, circulatory insufficiency, or nail problems that they seek nail
care from a podiatrist.
List at least four assessments you should make of a patient's hair. - (correct Answer) - The following
assessments should be made on a patient's hair:
● Use of special products or medicated shampoos
● History of hair problems or current conditions necessitating treatment (e.g., pediculosis [head lice])
● History or presence of disease or therapy that affect the hair (e.g., chemotherapy)
● Factors influencing the patient's ability to manage hair and scalp care (e.g., Impaired Mobility)
● Personal or cultural preferences for styling of the hair
● Condition, cleanliness, texture, and oiliness of the hair
● Inspection of the scalp for dandruff, pediculosis, alopecia (hair loss), secretions or lesions
What is pediculosis? - (correct Answer) - Pediculosis is an infestation of head lice
What is alopecia? - (correct Answer) - Alopecia is hair loss.
Identify the components of verbal and nonverbal communication. - (correct Answer) - Verbal
communication. Vocabulary, denotative and connotative meaning, pacing, intonation, clarity and brevity,
timing and relevance, credibility, and humor are the components of verbal communication.
● Nonverbal communication. Facial expression, posture and gait, personal appearance, distance,
gestures, and touch are the components of nonverbal communication.
What action should you take when there is a discrepancy between the client's spoken word and
nonverbal body language? - (correct Answer) - You must discuss the communication discrepancy with
the patient.
Identify and describe the phases of the therapeutic relationship. - (correct Answer) - The therapeutic
relationship has four phases: pre-interaction, orientation, working, and termination.
How can you estimate a client's tidal volume? - (correct Answer) - Tidal volume can be estimated by
observing the depth of the client's respirations.
What is the range of normal for an adult's respiratory rate? - (correct Answer) - A rate of 12 to 20 breaths
per minute is normal for adults
Besides the rate, what other characteristics of a client's respirations should you observe? - (correct
Answer) - Depth, rhythm, effort, breath sounds, and chest movement should be observed in addition to
rate.
What are some common clinical signs associated with poor oxygenation? - (correct Answer) - Pallor or
cyanosis of the nails, lips, or skin; restlessness; apprehension; confusion; dizziness; fatigue; changes in
pulse and blood pressure; and decreased level of consciousness are associated with poor oxygenation.
Which of the Korotkoff sounds would you record as the systolic pressure? - (correct Answer) - First
Which of the Korotkoff sounds would you record as the diastolic pressure? - (correct Answer) - Fifth
A nurse is auscultating a BP. He hears the first sound at 170 mm Hg. The sound disappears immediately.
At 150 mm Hg, the sound appears again and continues until there is silence at 80 mm Hg. The pressures
were taken in the client's right arm while the client was lying down.
How should the nurse record these pressures? - (correct Answer) - BP RA, supine, 170/80 with an
auscultatory gap from 170 to 150
How do you explain what happened? - (correct Answer) - An auscultatory gap occurred. A gap is most
commonly heard in hypertensive clients, whose systolic blood pressure is higher than the adult normal
limit of 140 mm Hg.
Which of the following patients has hypertension? One with a BP of:
150/80 on two separate occasions
180/100 on one occasion
138/88 on two occasions - (correct Answer) - 150/80 on two separate occasions
Which of the following client(s) has/have primary hypertension?
Client A, who is obese and has a high sodium intake
Client B, who is in renal failure
Client C, who has hypertension induced by pregnancy
,Client D, who has a family history of hypertension - (correct Answer) - Client D, who has a family history
of hypertension
What are five functions of the skin? - (correct Answer) - The skin serves five functions: protection,
sensation, temperature regulation, secretion/excretion, and formation of vitamin D.
How does the skin help regulate body temperature? - (correct Answer) - The skin contains sensory
organs or receptors for heat and cold. The skin regulates temperature through the process of dilating
and constricting blood vessels and activating or inactivating sweat glands. The sweat glands found in the
axillae and external genitalia secrete fatty acids and proteins and excrete perspiration, which produces a
cooling effect as the moisture evaporates from the skin.
What changes take place in the skin as a person ages - (correct Answer) - With age, both layers of the
skin become thinner and more fragile. As collagen and elastin fibers in the dermis deteriorate, the skin
becomes wrinkled. Sebaceous and sweat gland activity decreases, causing the skin to become dry, scaly,
and itchy, and temperature regulation in hot weather becomes more difficult. As the number and activity
of hair follicles and pigment cells (melanocytes) diminishes, hair becomes thin, turns gray or white, and
grows more slowly. Nails thicken and growth decreases. These changes increase the risk for skin
problems.
True or false: The professional nurse is responsible for making assessments. - (correct Answer) - True
True or false: Assisting with the bath is an excellent time to assess the patient. - (correct Answer) - True
To inspect for pallor in a dark-skinned person, which areas would you assess for an ashen gray or yellow
color? - (correct Answer) - For dark-skinned persons, the conjunctivae, buccal mucosa, tongue, lips, nail
beds, palms, and soles should be assessed for pallor.
What is the term that means "a bluish color of the skin"? - (correct Answer) - Cyanosis means a bluish
discoloration of the skin.
Name two causes of erythema. - (correct Answer) - Vasodilation and inflammation are causes of
erythema.
Where can you best see jaundice? - (correct Answer) - The sclera of the eyes is the best place to see
jaundice
True or false: Healthy nails are usually clean, smooth, and convexly curved - (correct Answer) - True
List at least three nail changes that occur with aging. - (correct Answer) - As a person ages, the nails
thicken, become ridged, and may yellow or become concave in shape.
List at least four things you should teach clients about self-care of their nails. - (correct Answer) -
Answer:
Clients should be taught the following self-care of their nails:
● Inspect the nails daily.
● Trim nails with a nail clipper (people with diabetes or circulatory problems should file only, as cutting
poses a risk for injury to the tissues).
, ● File the nails straight across, rounding the corners slightly to prevent scratching; do not cut deeply into
the lateral corners, as this may cause ingrown nails.
● Remove hangnails by carefully cutting them off.
● Clean under the nails with an orangewood stick or other blunt instrument.
● Push back the cuticles gently.
● Use a moisturizing lotion to soften cuticles.
● Avoid biting nails.
● Consult a podiatrist for any ingrown toenails or other nail problems.
● Recommend to patients with diabetes, circulatory insufficiency, or nail problems that they seek nail
care from a podiatrist.
List at least four assessments you should make of a patient's hair. - (correct Answer) - The following
assessments should be made on a patient's hair:
● Use of special products or medicated shampoos
● History of hair problems or current conditions necessitating treatment (e.g., pediculosis [head lice])
● History or presence of disease or therapy that affect the hair (e.g., chemotherapy)
● Factors influencing the patient's ability to manage hair and scalp care (e.g., Impaired Mobility)
● Personal or cultural preferences for styling of the hair
● Condition, cleanliness, texture, and oiliness of the hair
● Inspection of the scalp for dandruff, pediculosis, alopecia (hair loss), secretions or lesions
What is pediculosis? - (correct Answer) - Pediculosis is an infestation of head lice
What is alopecia? - (correct Answer) - Alopecia is hair loss.
Identify the components of verbal and nonverbal communication. - (correct Answer) - Verbal
communication. Vocabulary, denotative and connotative meaning, pacing, intonation, clarity and brevity,
timing and relevance, credibility, and humor are the components of verbal communication.
● Nonverbal communication. Facial expression, posture and gait, personal appearance, distance,
gestures, and touch are the components of nonverbal communication.
What action should you take when there is a discrepancy between the client's spoken word and
nonverbal body language? - (correct Answer) - You must discuss the communication discrepancy with
the patient.
Identify and describe the phases of the therapeutic relationship. - (correct Answer) - The therapeutic
relationship has four phases: pre-interaction, orientation, working, and termination.
