NSG 316 Final Exam: NSG 316 Final Exam Study
Guide: Questions & Answers: Verified 100%
Correct
Pain is always ____? - ANSWER -Subjective!
A patient with a severe muscle cramp tells the nurse, "The pain is a little better
when I massage the muscle or apply a cold pack." Which criterion of the PQRST
method of pain assessment is addressed in the patient's statement?
a. Severity Scale
b. Quality/Quantity
c. Region/Radiation
d. Provocation/Palliation - ANSWER -ANSWER: d
PQRST is a pain assessment scale; it stands for Provocation/Palliation,
Quality/Quantity, Region/Radiation, Severity Scale, and Timing. Because the
patient is describing methods that provide comfort and relieve the pain, it indicates
that the patient is addressing Provocation/Palliation. If the patient reports about
severity of pain on a scale of 0 to 10, then it indicates that the patient is addressing
Severity. When addressing the Quality/Quantity of the pain, the patient describes
the pain felt. If the patient reports about the site of pain, then the patient is
addressing Region/Radiation.
Stages of Edema - ANSWER -1+ mild, slight indentation, no perceptible swelling
2+ moderate, indentation subsides rapidly (seconds)
3+ deep, indentation remains for short time (minutes), appears swollen
4+ very deep, indentation lasts long time (hours), appears very swollen
Skin assessment for a head-to-toe assessment - ANSWER -1. Check skin for
temperature w/ back of hands and inspect
- skin is warm, dry, intact, color is consistent throughout, no lesins, scars, tattoos
noted on exposed skin
, 2. Skin turgor - appropriate B/L, no tenting noted
3. Upper body edema
4. Radial pulses - strong, palpable, equal, and approximately 2+
5. Capillary refill -
<2 sec B/L
Test for CN V - ANSWER -CN V (trigeminal) - clench jaw, use cotton ball to
touch different areas of the face while patient has eyes closed
Test for CN VII - ANSWER -CN VII (facial) - raise eyebrows, close eyes, puff
out cheeks, smile, frown
Test for CN III, IV, VI - ANSWER -CN III (oculomotor) IV (trochlear) VI
(abducens) - six cardinal fields of gaze; follow penlight w/o moving head
Test for CN XI - ANSWER -CN XI (spinal accessory) - ROM of neck is equal and
strength in shoulders is equal w/ and w/o resistance
HEENMT - ANSWER -- Head is normocephalic, face is symmetrical, neck is
proportionate to head and face, and hair distribution is normal
- Pupils are equal, round, reactive to light (direct and consensual), and
accommodated. Convergence is noted B/L, pupil size, no drainage or jaundice,
symmetrical, sclera white, conjunctive pink
- Ears are symmetrical, intact, skin color is consistent with exposed skin, pinna
(pull up) and tragus (push in) are mobile and nontender
- Nose is midline, nares are symmetrical and patent
- Tongue and buccal mucosa are pink, moist, and w/o lesions, dentition intact
- Trachea is midline
Test for CN IX - ANSWER -CN IX (glossopharyngeal) - say "ahhh"; uvula rises
w/ phonation
Test for CN XII - ANSWER -CN XII (hypoglossal) - Say "light, tight, dynamite"
Guide: Questions & Answers: Verified 100%
Correct
Pain is always ____? - ANSWER -Subjective!
A patient with a severe muscle cramp tells the nurse, "The pain is a little better
when I massage the muscle or apply a cold pack." Which criterion of the PQRST
method of pain assessment is addressed in the patient's statement?
a. Severity Scale
b. Quality/Quantity
c. Region/Radiation
d. Provocation/Palliation - ANSWER -ANSWER: d
PQRST is a pain assessment scale; it stands for Provocation/Palliation,
Quality/Quantity, Region/Radiation, Severity Scale, and Timing. Because the
patient is describing methods that provide comfort and relieve the pain, it indicates
that the patient is addressing Provocation/Palliation. If the patient reports about
severity of pain on a scale of 0 to 10, then it indicates that the patient is addressing
Severity. When addressing the Quality/Quantity of the pain, the patient describes
the pain felt. If the patient reports about the site of pain, then the patient is
addressing Region/Radiation.
Stages of Edema - ANSWER -1+ mild, slight indentation, no perceptible swelling
2+ moderate, indentation subsides rapidly (seconds)
3+ deep, indentation remains for short time (minutes), appears swollen
4+ very deep, indentation lasts long time (hours), appears very swollen
Skin assessment for a head-to-toe assessment - ANSWER -1. Check skin for
temperature w/ back of hands and inspect
- skin is warm, dry, intact, color is consistent throughout, no lesins, scars, tattoos
noted on exposed skin
, 2. Skin turgor - appropriate B/L, no tenting noted
3. Upper body edema
4. Radial pulses - strong, palpable, equal, and approximately 2+
5. Capillary refill -
<2 sec B/L
Test for CN V - ANSWER -CN V (trigeminal) - clench jaw, use cotton ball to
touch different areas of the face while patient has eyes closed
Test for CN VII - ANSWER -CN VII (facial) - raise eyebrows, close eyes, puff
out cheeks, smile, frown
Test for CN III, IV, VI - ANSWER -CN III (oculomotor) IV (trochlear) VI
(abducens) - six cardinal fields of gaze; follow penlight w/o moving head
Test for CN XI - ANSWER -CN XI (spinal accessory) - ROM of neck is equal and
strength in shoulders is equal w/ and w/o resistance
HEENMT - ANSWER -- Head is normocephalic, face is symmetrical, neck is
proportionate to head and face, and hair distribution is normal
- Pupils are equal, round, reactive to light (direct and consensual), and
accommodated. Convergence is noted B/L, pupil size, no drainage or jaundice,
symmetrical, sclera white, conjunctive pink
- Ears are symmetrical, intact, skin color is consistent with exposed skin, pinna
(pull up) and tragus (push in) are mobile and nontender
- Nose is midline, nares are symmetrical and patent
- Tongue and buccal mucosa are pink, moist, and w/o lesions, dentition intact
- Trachea is midline
Test for CN IX - ANSWER -CN IX (glossopharyngeal) - say "ahhh"; uvula rises
w/ phonation
Test for CN XII - ANSWER -CN XII (hypoglossal) - Say "light, tight, dynamite"
