NURS 202 UPDATED EXAMS SCRIPT QUESTIONS AND
ANSWERS GRADED A+
✔✔Stage 1 PU - ✔✔-Non-blanchable, intact, red skin
-In darker skin it may not be red but just darker, still nonblanching
✔✔Stage 2 PU - ✔✔-Superficial dermis loss
-Appears pink or red
-NO yellow, tan, brown, or black tissue
-May have fluid-filled blisters
✔✔Stage 3 PU - ✔✔-Full thickness loss, tissue damage past dermis
-Deep or shallow, but you can see to the bottom of the wound
-Defining: Yellow tissue present
-May include undermining or tunneling
✔✔Stage 4 PU - ✔✔-Full thickness loss with muscle or bone exposure
-Yellow slough or eschar may be present
-Often has undermining and/or tunneling
-Usually not painful because all of the nerves have been destroyed. Eschar
may be painful and have to be taken off
✔✔Unstageable PU - ✔✔Full thickness loss but yellow slough or eschar prevents you
from being
able to view the bed of the wound
✔✔Suspected deep tissue injury - ✔✔-Purple or maroon area of discoloration that
indicates damage of
underlying tissue structures
-Skin is usually intact, but can present as a blood filled blister
-Compared to the surrounding tissue, the area may be painful, hard, mushy,
warmer, cooler, firm, or boggy.
-Would be able to squish the blood around
-Can happen if someone falls from a high height. Also seen in childhood
injuries of someone who has been abused/beaten
✔✔Effects of Noise on Sleep - ✔✔No bueno, don't wake people up in the middle of the
night for vitals maybe???
✔✔Maslows Hierarchy of Needs - ✔✔-Physiological
-Safety
-Love/Belonging
-Esteem
-Self-Actualization
, ✔✔Angina - ✔✔Type of chest pain associated with reduced blood flow to the heart
often described as squeezing, pressure, heaviness, or tightness
✔✔Ischemia - ✔✔Inadequate blood supply to an organ or part of the body--cardiac
ischemia may cause angina
✔✔Emergency HR - ✔✔Carotid
✔✔Apical Pulse - ✔✔-Children under 2
-Also preferred for children under 10
✔✔Decreased RBC - ✔✔More blood movement throughout body in order to adequately
oxygenate tissue
✔✔Left Ventricle - ✔✔Problem with blood flow to body
✔✔Right Ventricle - ✔✔Problem with blood flow to lungs
✔✔Compensatory Mechanism - ✔✔-Increases HR
-Increases RR
✔✔Constipation - Causes - ✔✔-Medication
-Diet Change
-Pain
-Immobility
-Anxiety/Stress
-Anesthesia
✔✔Valsalva Maneuver - ✔✔-Causes vasovagal response of bradycardia, hypotension,
and passing out
-Risk in CVD patients
✔✔Diarrhea - ✔✔-5-6 loose stools in 24 hr period
-Alkaine, could lead to metabolic acidosis
-Risk of skin breakdown and fluid/electrolyte imbalances
✔✔Tube feeding - ✔✔Never leave tube feeding for more than 4 hours
✔✔Continuous Feeding - ✔✔-Allows gradual introduction of the formula, promoting max
absorption
-Requires use of enteral feeding pump, which limits mobility and increases cost
-Aspiration and reflux risk
-All feedings directly to intestines must be continuous
ANSWERS GRADED A+
✔✔Stage 1 PU - ✔✔-Non-blanchable, intact, red skin
-In darker skin it may not be red but just darker, still nonblanching
✔✔Stage 2 PU - ✔✔-Superficial dermis loss
-Appears pink or red
-NO yellow, tan, brown, or black tissue
-May have fluid-filled blisters
✔✔Stage 3 PU - ✔✔-Full thickness loss, tissue damage past dermis
-Deep or shallow, but you can see to the bottom of the wound
-Defining: Yellow tissue present
-May include undermining or tunneling
✔✔Stage 4 PU - ✔✔-Full thickness loss with muscle or bone exposure
-Yellow slough or eschar may be present
-Often has undermining and/or tunneling
-Usually not painful because all of the nerves have been destroyed. Eschar
may be painful and have to be taken off
✔✔Unstageable PU - ✔✔Full thickness loss but yellow slough or eschar prevents you
from being
able to view the bed of the wound
✔✔Suspected deep tissue injury - ✔✔-Purple or maroon area of discoloration that
indicates damage of
underlying tissue structures
-Skin is usually intact, but can present as a blood filled blister
-Compared to the surrounding tissue, the area may be painful, hard, mushy,
warmer, cooler, firm, or boggy.
-Would be able to squish the blood around
-Can happen if someone falls from a high height. Also seen in childhood
injuries of someone who has been abused/beaten
✔✔Effects of Noise on Sleep - ✔✔No bueno, don't wake people up in the middle of the
night for vitals maybe???
✔✔Maslows Hierarchy of Needs - ✔✔-Physiological
-Safety
-Love/Belonging
-Esteem
-Self-Actualization
, ✔✔Angina - ✔✔Type of chest pain associated with reduced blood flow to the heart
often described as squeezing, pressure, heaviness, or tightness
✔✔Ischemia - ✔✔Inadequate blood supply to an organ or part of the body--cardiac
ischemia may cause angina
✔✔Emergency HR - ✔✔Carotid
✔✔Apical Pulse - ✔✔-Children under 2
-Also preferred for children under 10
✔✔Decreased RBC - ✔✔More blood movement throughout body in order to adequately
oxygenate tissue
✔✔Left Ventricle - ✔✔Problem with blood flow to body
✔✔Right Ventricle - ✔✔Problem with blood flow to lungs
✔✔Compensatory Mechanism - ✔✔-Increases HR
-Increases RR
✔✔Constipation - Causes - ✔✔-Medication
-Diet Change
-Pain
-Immobility
-Anxiety/Stress
-Anesthesia
✔✔Valsalva Maneuver - ✔✔-Causes vasovagal response of bradycardia, hypotension,
and passing out
-Risk in CVD patients
✔✔Diarrhea - ✔✔-5-6 loose stools in 24 hr period
-Alkaine, could lead to metabolic acidosis
-Risk of skin breakdown and fluid/electrolyte imbalances
✔✔Tube feeding - ✔✔Never leave tube feeding for more than 4 hours
✔✔Continuous Feeding - ✔✔-Allows gradual introduction of the formula, promoting max
absorption
-Requires use of enteral feeding pump, which limits mobility and increases cost
-Aspiration and reflux risk
-All feedings directly to intestines must be continuous
