NR 304 EXAM 9 ALL QUESTIONS WITH CORRECT
ANSWERS
What are the effects of smoking on blood pressure?
Asymmetry, border irregularity, color variation, diameter greater than 6mm,
elevation/evolution, funny looking
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
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°
How do you assess for clubbing?
Smoking, lung cancer, pulmonary disease, congenital cyanotic heart disease
What patients does clubbing occur?
Generalized pallor
How do you detect pallor in a light skinned patient?
Ashen gray, dull, loss of glow, cool to palpation
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
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.
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
, What is a problem center database? Give an example.
Begins during first patient encounter.. Includes their physical appearance,
body structure, mobility, behavior, body measurements
What are the components of a general survey?
3+ Full, bounding
2+ Normal
1+ Weak, thready
0 Absent
What is the grading of pulse force?
Acute myocardial infarction, shock, hemorrhage, vasodilation, Addison's
disease
What are causes of hypotension?
Less than 95/60 mmHg
What is the blood pressure measurement for hypotension?
Decreased
Acute myocardial infarction and shark causes a _____ cardiac output which leads to
hypertension?
decreased
Hemorrhage causes a _____ total blood volume that leads to hypotension
decreased
Vasodilation causes a ____peripheral vascular resistance that leads to hypotension
decreased
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
How do you count respirations?
Vasoconstriction of the arteries which makes your blood pressure increase.
Long-term cause of hypertension
Yellow sclera, hard palate, skin, mucous membranes
How do you detect jaundice in a light-skinned patient?
Observe the palms, hard and soft palates
How do you observe jaundice in a dark skinned patient?
Dusky blue appearance
ANSWERS
What are the effects of smoking on blood pressure?
Asymmetry, border irregularity, color variation, diameter greater than 6mm,
elevation/evolution, funny looking
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
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°
How do you assess for clubbing?
Smoking, lung cancer, pulmonary disease, congenital cyanotic heart disease
What patients does clubbing occur?
Generalized pallor
How do you detect pallor in a light skinned patient?
Ashen gray, dull, loss of glow, cool to palpation
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
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.
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
, What is a problem center database? Give an example.
Begins during first patient encounter.. Includes their physical appearance,
body structure, mobility, behavior, body measurements
What are the components of a general survey?
3+ Full, bounding
2+ Normal
1+ Weak, thready
0 Absent
What is the grading of pulse force?
Acute myocardial infarction, shock, hemorrhage, vasodilation, Addison's
disease
What are causes of hypotension?
Less than 95/60 mmHg
What is the blood pressure measurement for hypotension?
Decreased
Acute myocardial infarction and shark causes a _____ cardiac output which leads to
hypertension?
decreased
Hemorrhage causes a _____ total blood volume that leads to hypotension
decreased
Vasodilation causes a ____peripheral vascular resistance that leads to hypotension
decreased
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
How do you count respirations?
Vasoconstriction of the arteries which makes your blood pressure increase.
Long-term cause of hypertension
Yellow sclera, hard palate, skin, mucous membranes
How do you detect jaundice in a light-skinned patient?
Observe the palms, hard and soft palates
How do you observe jaundice in a dark skinned patient?
Dusky blue appearance
