Fully Solved
Prioritize the nursing actions - Answer ABC rule:
Airway
Breathing
Circulation
two-point discrimination: Fingers - Answer 2-3 mm
two-point discrimination: Palm - Answer 10 mm
two-point discrimination: Forearm - Answer 35 mm
Two-point discrimination: Upper arm - Answer 39
Cranial Nerves - Answer 12 pairs of nerves that carry messages to and from the brain
Nerve I - Answer Olfactory
Nerve II - Answer Optic
Nerve III - Answer Oculomotor
Nerve IV - Answer Trochlear
Nerve V - Answer Trigeminal
Nerve VI - Answer Abducens
, Nerve VII - Answer Facial
Nerve VIII - Answer Acoustic
Nerve IX - Answer Glossopharyngeal
Nerve X - Answer Vagus
Nerve XI - Answer spinal accessory
Nerve XII - Answer Hypoglossal
Hips ROM Osteoarthritis - Answer Pain increases at night, movement increases pain
Reasons for enlarged spleen - Answer traumatic injury
acute infection (mono)
referred chest pain, back, mid/upper R section of abd.
Hemorrhoids - Answer painless, flabby pa-pules, are cause by varicose veins. Thrombosed, contains
clotted blood and becomes painful, swollen, shiny blue mass that itches and bleeds with deification.
Occur with straining stool, chronic constipation, pregnancy, obesity, chronic liver disease, low fiber diet.
ascites assessment - Answer pathologic increase in fluid in peritoneal cavity- percuss for dullness and
resonance, shifting dullness, fluid wave
breast exam - Answer early detection is important. Every woman should preform exam monthly, as soon
as menstrual bleeding has ceased or if postmenopausal same date every month.