Nur 211 Final Exam
Explain the correct way to palpate the breast. p. 359-361 - -Pt supine with arm over head -
There are several different techniques to assess for lumps. It is important that the nurse has a
systematic search pattern to thoroughly assess each breast, the tail of Spence, and axillary lymph
nodes.
--Circular pattern for palpation - -starts by palpating the areola first and moving in a circular motion
from the areola to the outer perimeter of the breast
--Radial spoke pattern for palpation - -also known as the wedge pattern, divides the breast into
wedges; starts at the periphery of the breast and palpates toward the nipple
--Vertical strip pattern for palpation - -starts at the sternum palpating up and down in straight lines
toward the outer perimeter of the breast, ending up in the axillary area
--Describe the correct positioning for conducting a pap smear. p.363-364 - -Ask the patient to
undress from the waist down, but tell her that she may leave her socks on; provide a gown, draping,
and privacy for the patient.
■ Tell the patient that she can sit at the end of the examination table until the healthcare provider is
ready to perform the assessment; the healthcare provider will assist the patient into the lithotomy
position.
When the healthcare provider is ready to begin, assist the patient into the lithotomy position by
having the patient move her buttocks down to the end of the examination table; ask the patient to
place the heels of her feet into the stirrups; assist the patient as needed for comfort and safety.
Provide a sheet over her legs and knees for privacy until the assessment begins.
--Explain the needed patient teaching to treat and prevent constipation - -Eat a High fiber Diet, Eat
fruits, veg and whole grains
Avoid high fat foods like meat, eggs and cheese (dairy)
Stay hydrated but avoid caffeine and alcohol (these will dehydrate you)
keep moving around and exercise
If needed- stool softener or laxatives
Do not read or be on phone while on toilet
--Discuss the causes of projectile vomiting in adults. p.247 - -Projectile vomiting without nausea is a
sign of central stimulation of the medulla; could be a sign of brain pathology or head trauma.
--Identify the 3 organs located at the midline. p.251 - -Aorta
Uterus
Bladder
--Describe how the jugular vein changes with congestive heart failure. p.272 - -Visible distention is a
sign of venous pressure elevation, commonly seen in congestive heart failure and fluid overload.
--Identify where the brachial, carotid, femoral and tibial pulses are located and palpated. - -Brachial
Pulse : Medial side of arm at the antecubital fossa space.
Carotid Pulse: between the trachea and sternocleidomastoid muscle.
Femoral Pulse:along the crease midway between the pubic bone and the anterior iliac crest.
Tibial Pulse: behind and below the medial malleolus.
, --Explain the rationale for the elderly's noncompliance with prescribed medicines. - -Most cases
(75%) of nonadherence among older adults are intentional due to cost or side effects of drugs
--Identify the sound of percussion of the abdomen when there is air, fluid, or a hematoma present. -
-Air-hollow, fluid - thudding sound, hematoma - (there would be visual representation)
--Explain all the steps for starting any physical assessment on a patient. (Accept the abdomen) - -
inspection, palpation, percussion, auscultation
--Explain the necessary teaching for male patients with a family history of breast cancer. - -most
common presentation of male breast cancer is painless, palpable, subareolar lump or mass. may also
present as erythema of skin, scaling of the nipple, or nipple discharge
--List the health screenings recommended for male patients and their frequency. - -testicular exam
by doctor annually and self exams routinely
prostate screenings annually for men over age 50 or high risk men age 40+
male breast exam - self exam . for men with fam hx of breast cancer semiannual clinical exam
(starting at age 35) baseline mamogram at age 40
--Identify the elements of good patient care documentation. - -documentation should be clear,
concise, and detailed. subjective data should be documented using the patients exact words and
quotation marks
--Identify the purpose of health assessment for nurses. - -Health assessment is an essential skill to
nursing practice. Assessing patients and being able to identify normal from abnormal findings is an
essential role of the RN. Nurses must be able to use learned skills to collect information about
patients' health and physical well-being.
Health assessment means assessing the whole patient. This includes:
A method to establish a baseline health history by collecting pertinent patient health status data
An organized, systematic, ongoing process of collecting, validating, and clustering data
Collecting different types of data about the individual's past and present health
Assessing factors influencing health and well-being, including
physical health
behavioral aspects of health
spirituality
social factors
economic-political aspects of health
cultural variations
lifespan and developmental considerations
Performing a physical examination.
--Define the following integumentary conditions found in the elderly: bulbus hematoma,
subcutaneous abrasions, senile purpura, and epithelial contusions. - -bulbus hematoma - bulging
subcutaneous abrasions - first few layers are rubbed away (stage 2 ulcer)
senile purpura - areas of ruptured fagile cappillaries and brusing of of the skin, caused by loss of
subcutaneous fat (bruise or echhymosis area)
epithelial contusions - Think goose egg
--Explain how best practices of health assessment are validated. - -Nurses need to maintain currency
in their profession. Best practice assessments and instruments have been validated by research.
Explain the correct way to palpate the breast. p. 359-361 - -Pt supine with arm over head -
There are several different techniques to assess for lumps. It is important that the nurse has a
systematic search pattern to thoroughly assess each breast, the tail of Spence, and axillary lymph
nodes.
--Circular pattern for palpation - -starts by palpating the areola first and moving in a circular motion
from the areola to the outer perimeter of the breast
--Radial spoke pattern for palpation - -also known as the wedge pattern, divides the breast into
wedges; starts at the periphery of the breast and palpates toward the nipple
--Vertical strip pattern for palpation - -starts at the sternum palpating up and down in straight lines
toward the outer perimeter of the breast, ending up in the axillary area
--Describe the correct positioning for conducting a pap smear. p.363-364 - -Ask the patient to
undress from the waist down, but tell her that she may leave her socks on; provide a gown, draping,
and privacy for the patient.
■ Tell the patient that she can sit at the end of the examination table until the healthcare provider is
ready to perform the assessment; the healthcare provider will assist the patient into the lithotomy
position.
When the healthcare provider is ready to begin, assist the patient into the lithotomy position by
having the patient move her buttocks down to the end of the examination table; ask the patient to
place the heels of her feet into the stirrups; assist the patient as needed for comfort and safety.
Provide a sheet over her legs and knees for privacy until the assessment begins.
--Explain the needed patient teaching to treat and prevent constipation - -Eat a High fiber Diet, Eat
fruits, veg and whole grains
Avoid high fat foods like meat, eggs and cheese (dairy)
Stay hydrated but avoid caffeine and alcohol (these will dehydrate you)
keep moving around and exercise
If needed- stool softener or laxatives
Do not read or be on phone while on toilet
--Discuss the causes of projectile vomiting in adults. p.247 - -Projectile vomiting without nausea is a
sign of central stimulation of the medulla; could be a sign of brain pathology or head trauma.
--Identify the 3 organs located at the midline. p.251 - -Aorta
Uterus
Bladder
--Describe how the jugular vein changes with congestive heart failure. p.272 - -Visible distention is a
sign of venous pressure elevation, commonly seen in congestive heart failure and fluid overload.
--Identify where the brachial, carotid, femoral and tibial pulses are located and palpated. - -Brachial
Pulse : Medial side of arm at the antecubital fossa space.
Carotid Pulse: between the trachea and sternocleidomastoid muscle.
Femoral Pulse:along the crease midway between the pubic bone and the anterior iliac crest.
Tibial Pulse: behind and below the medial malleolus.
, --Explain the rationale for the elderly's noncompliance with prescribed medicines. - -Most cases
(75%) of nonadherence among older adults are intentional due to cost or side effects of drugs
--Identify the sound of percussion of the abdomen when there is air, fluid, or a hematoma present. -
-Air-hollow, fluid - thudding sound, hematoma - (there would be visual representation)
--Explain all the steps for starting any physical assessment on a patient. (Accept the abdomen) - -
inspection, palpation, percussion, auscultation
--Explain the necessary teaching for male patients with a family history of breast cancer. - -most
common presentation of male breast cancer is painless, palpable, subareolar lump or mass. may also
present as erythema of skin, scaling of the nipple, or nipple discharge
--List the health screenings recommended for male patients and their frequency. - -testicular exam
by doctor annually and self exams routinely
prostate screenings annually for men over age 50 or high risk men age 40+
male breast exam - self exam . for men with fam hx of breast cancer semiannual clinical exam
(starting at age 35) baseline mamogram at age 40
--Identify the elements of good patient care documentation. - -documentation should be clear,
concise, and detailed. subjective data should be documented using the patients exact words and
quotation marks
--Identify the purpose of health assessment for nurses. - -Health assessment is an essential skill to
nursing practice. Assessing patients and being able to identify normal from abnormal findings is an
essential role of the RN. Nurses must be able to use learned skills to collect information about
patients' health and physical well-being.
Health assessment means assessing the whole patient. This includes:
A method to establish a baseline health history by collecting pertinent patient health status data
An organized, systematic, ongoing process of collecting, validating, and clustering data
Collecting different types of data about the individual's past and present health
Assessing factors influencing health and well-being, including
physical health
behavioral aspects of health
spirituality
social factors
economic-political aspects of health
cultural variations
lifespan and developmental considerations
Performing a physical examination.
--Define the following integumentary conditions found in the elderly: bulbus hematoma,
subcutaneous abrasions, senile purpura, and epithelial contusions. - -bulbus hematoma - bulging
subcutaneous abrasions - first few layers are rubbed away (stage 2 ulcer)
senile purpura - areas of ruptured fagile cappillaries and brusing of of the skin, caused by loss of
subcutaneous fat (bruise or echhymosis area)
epithelial contusions - Think goose egg
--Explain how best practices of health assessment are validated. - -Nurses need to maintain currency
in their profession. Best practice assessments and instruments have been validated by research.
