NR 304 Final Exam – Questions With Proven Solutions
Progress towards outcomes, use ongoing assessment to revise
diagnoses/outcomes/plans, disseminate results to patient and family
Correct Answer - What happens during the evaluation step of the nursing
process?
Compare clinical findings with normal and abnormal variation and
developmental events, interpret data, validate and document diagnoses.
Correct Answer - What happens during the diagnosis stage of the nursing
process?
For limited or short term problems. Collect mini/targeted databases. Focuses
on only one problem or body system and is used in all clinical settings.
Ex: two days post-op patient suddenly becomes SOB with congestive cough
and fatigue; focus on respiratory and cardiovascular systems Correct
Answer - What is a problem center database? Give an example.
Begins during first patient encounter.. Includes their physical appearance,
body structure, mobility, behavior, body measurements Correct Answer -
What are the components of a general survey?
3+ Full, bounding
2+ Normal
1+ Weak, thready
0 Absent Correct Answer - What is the grading of pulse force?
Acute myocardial infarction, shock, hemorrhage, vasodilation, Addison's
disease Correct Answer - What are causes of hypotension?
Less than 95/60 mmHg Correct Answer - What is the blood pressure
measurement for hypotension?
Decreased Correct Answer - Acute myocardial infarction and shark
causes a _____ cardiac output which leads to hypertension?
decreased Correct Answer - Hemorrhage causes a _____ total blood
volume that leads to hypotension
, decreased Correct Answer - Vasodilation causes a ____peripheral
vascular resistance that leads to hypotension
decreased Correct Answer - Addison's disease (hypofunction of adrenal
gland) is caused by a ___ circulating aldosterone which causes hypotension
Count while assessing radial pulse to make patient unaware that you were
counting respirations. Count for 30 seconds of normal or 1 minute if abnormal
Correct Answer - How do you count respirations?
Vasoconstriction of the arteries which makes your blood pressure increase.
Long-term cause of hypertension Correct Answer - What are the effects
of smoking on blood pressure?
Asymmetry, border irregularity, color variation, diameter greater than 6mm,
elevation/evolution, funny looking Correct Answer - What is the
ABCDEF skin lesions mean?
Tachycardia, elevated blood pressure, increased cardiac output, hypoxia,
hypoventilation, atelectasis, decreased cough, nausea, vomiting, ileus, oliguria,
urinary retention, spasm, joint stiffness, increased adrenergic activity, fear,
anxiety, fatigue, impaired immunity, wound healing Correct Answer -
What are the physiological changes associated with acute pain responses?
Put nail beds back to back and view profile sign index. Normal is 160°. Early
clubbing is 180° and lake clubbing is anything less than 160° Correct
Answer - How do you assess for clubbing?
Smoking, lung cancer, pulmonary disease, congenital cyanotic heart disease
Correct Answer - What patients does clubbing occur?
Generalized pallor Correct Answer - How do you detect pallor in a light
skinned patient?
Ashen gray, dull, loss of glow, cool to palpation Correct Answer - How do
you detect pallor in a dark skinned patient?
Progress towards outcomes, use ongoing assessment to revise
diagnoses/outcomes/plans, disseminate results to patient and family
Correct Answer - What happens during the evaluation step of the nursing
process?
Compare clinical findings with normal and abnormal variation and
developmental events, interpret data, validate and document diagnoses.
Correct Answer - What happens during the diagnosis stage of the nursing
process?
For limited or short term problems. Collect mini/targeted databases. Focuses
on only one problem or body system and is used in all clinical settings.
Ex: two days post-op patient suddenly becomes SOB with congestive cough
and fatigue; focus on respiratory and cardiovascular systems Correct
Answer - What is a problem center database? Give an example.
Begins during first patient encounter.. Includes their physical appearance,
body structure, mobility, behavior, body measurements Correct Answer -
What are the components of a general survey?
3+ Full, bounding
2+ Normal
1+ Weak, thready
0 Absent Correct Answer - What is the grading of pulse force?
Acute myocardial infarction, shock, hemorrhage, vasodilation, Addison's
disease Correct Answer - What are causes of hypotension?
Less than 95/60 mmHg Correct Answer - What is the blood pressure
measurement for hypotension?
Decreased Correct Answer - Acute myocardial infarction and shark
causes a _____ cardiac output which leads to hypertension?
decreased Correct Answer - Hemorrhage causes a _____ total blood
volume that leads to hypotension
, decreased Correct Answer - Vasodilation causes a ____peripheral
vascular resistance that leads to hypotension
decreased Correct Answer - Addison's disease (hypofunction of adrenal
gland) is caused by a ___ circulating aldosterone which causes hypotension
Count while assessing radial pulse to make patient unaware that you were
counting respirations. Count for 30 seconds of normal or 1 minute if abnormal
Correct Answer - How do you count respirations?
Vasoconstriction of the arteries which makes your blood pressure increase.
Long-term cause of hypertension Correct Answer - What are the effects
of smoking on blood pressure?
Asymmetry, border irregularity, color variation, diameter greater than 6mm,
elevation/evolution, funny looking Correct Answer - What is the
ABCDEF skin lesions mean?
Tachycardia, elevated blood pressure, increased cardiac output, hypoxia,
hypoventilation, atelectasis, decreased cough, nausea, vomiting, ileus, oliguria,
urinary retention, spasm, joint stiffness, increased adrenergic activity, fear,
anxiety, fatigue, impaired immunity, wound healing Correct Answer -
What are the physiological changes associated with acute pain responses?
Put nail beds back to back and view profile sign index. Normal is 160°. Early
clubbing is 180° and lake clubbing is anything less than 160° Correct
Answer - How do you assess for clubbing?
Smoking, lung cancer, pulmonary disease, congenital cyanotic heart disease
Correct Answer - What patients does clubbing occur?
Generalized pallor Correct Answer - How do you detect pallor in a light
skinned patient?
Ashen gray, dull, loss of glow, cool to palpation Correct Answer - How do
you detect pallor in a dark skinned patient?
