NSG 312 NURSING ASSESSMENT FINAL UPDATED
ACTUAL QUESTIONS AND CORRECT ANSWERS
Question:
What are universal fall precautions?
Answer:
Universal fall precautions are called "universal" because they apply to all patients
regardless of fall risk. Universal fall precautions revolve around keeping the patient's
environment safe and comfortable. -Familiarize the patient with the environment.
-Have the patient demonstrate call light use. -Maintain call light within reach. -Keep the
patient's personal possessions within patient safe reach. -Have sturdy handrails in
patient bathrooms, room, and hallway. -Place the hospital bed in low position when a
patient is resting in bed; raise bed to a comfortable height when the patient is
transferring out of bed. -Keep hospital bed brakes locked. -Keep wheelchair wheel locks
in "locked" position when stationary. -Keep nonslip, comfortable, well-fitting footwear
on the patient. -Use night lights or supplemental lighting. -Keep floor surfaces clean and
dry. Clean up all spills promptly. -Keep patient care areas uncluttered. -Follow safe
patient handling practices.
Question:
Possible causes of chest pain
Answer:
-Cardiac -Aortic -Musculoskeletal -Pleural -Gastrointestinal -Pulmonary -Psychoneurotic
-Rule out cardiac before other options -Chest pain in children and adolescents is seldom
due to a cardiac problem. -In assessment of chest pain in adults - assume cardiac until
proven otherwise
Question:
Where should you start counting intercostal spaces?
Answer:
The angle of Louis (also called the sternal angle) is a useful place to start counting ribs.
If you find the sternal notch, walk your fingers down the manubrium a few centimeters
until you feel a distinct bony ridge. This is the sternal angle. The 2nd rib is continuous
with the sternal angle;
slide your finger down to localize the 2nd intercostal space. The angle of Louis also
marks the site of bifurcation of the trachea into the right and left main bronchi and
corresponds with the upper border of the atria of the heart
Question:
Where do you palpate on the chest?
Answer:
Palpate the base, left sternal border and apex Mid-clavicular line, 5th intercostal space,
palpate PMI with one finger (located under breast tissue in women) assess location of
PMI (point of maximal impulse or apical impulse)
, Question:
Order of auscultation of the heart.
Answer:
A- aortic P - pulmonic T - tricuspid E - erbs point M - mitral 22345 Second ICS R of
sternum Second ICS L of sternum Third ICS L of sternum Fourth ICS L of sternum Fifth
ICS mid clavicular
Question:
Use of the Stethoscope:
-diaphragm -bell
Answer:
Diaphragm -High pitched sounds -Best for hearing S1 and S2 -(bowel, breath, normal
cardiac) Bell -Low pitched sounds -Use for hearing S3 and S4 -Use to assess for carotid
bruits -heart murmurs
Question:
Order of blood flow through the heart
Answer:
right atrium > tricuspid > right ventricle > pulmonary semilunar valve > pulmonary
veins > left atrium > mitral /bicuspid > left ventricle > aortic semilunar valve
Question:
Cardiac Cycle sounds:
-S1 -S2
Answer:
Systole -Heart sound = S1 - lub -Contraction and emptying of the atria and ventricles
-Aortic and pulmonic valves open -mitral and tricuspid valves close -S1 loudest at apex
Diastole -Heart sound = S2 - dub -Relaxation and filling of the atria and ventricles
-Aortic and pulmonic valves close -Mitral and tricuspid valves open -S2 loudest at base
Question:
Extra heart sounds:
S3 & S4
Answer:
S3... Due to Rapid ventricular filling: ventricular gallop S1 -- S2-S3 (Ken--tuc-ky) -Low
frequency sound in early diastole S4... Due to slow ventricular contraction: atrial gallop
S4-S1 - S2 (Ten-nes-see) -Low frequency sound in presystolic portion of diastole
Question:
S3 Heart Sound is resulted from what?
Answer:
Results from increased atrial pressure leading to increased flow rates, as seen in
congestive heart failure, which is the most common cause of a S3. Associated dilated
cardiomyopathy with dilated ventricles also contribute to the sound. Less commonly,
valvular regurgitation and left to right shunts may also result in a S3 due to increased
flow. May be normal physiological finding in patients less than age 40
ACTUAL QUESTIONS AND CORRECT ANSWERS
Question:
What are universal fall precautions?
Answer:
Universal fall precautions are called "universal" because they apply to all patients
regardless of fall risk. Universal fall precautions revolve around keeping the patient's
environment safe and comfortable. -Familiarize the patient with the environment.
-Have the patient demonstrate call light use. -Maintain call light within reach. -Keep the
patient's personal possessions within patient safe reach. -Have sturdy handrails in
patient bathrooms, room, and hallway. -Place the hospital bed in low position when a
patient is resting in bed; raise bed to a comfortable height when the patient is
transferring out of bed. -Keep hospital bed brakes locked. -Keep wheelchair wheel locks
in "locked" position when stationary. -Keep nonslip, comfortable, well-fitting footwear
on the patient. -Use night lights or supplemental lighting. -Keep floor surfaces clean and
dry. Clean up all spills promptly. -Keep patient care areas uncluttered. -Follow safe
patient handling practices.
Question:
Possible causes of chest pain
Answer:
-Cardiac -Aortic -Musculoskeletal -Pleural -Gastrointestinal -Pulmonary -Psychoneurotic
-Rule out cardiac before other options -Chest pain in children and adolescents is seldom
due to a cardiac problem. -In assessment of chest pain in adults - assume cardiac until
proven otherwise
Question:
Where should you start counting intercostal spaces?
Answer:
The angle of Louis (also called the sternal angle) is a useful place to start counting ribs.
If you find the sternal notch, walk your fingers down the manubrium a few centimeters
until you feel a distinct bony ridge. This is the sternal angle. The 2nd rib is continuous
with the sternal angle;
slide your finger down to localize the 2nd intercostal space. The angle of Louis also
marks the site of bifurcation of the trachea into the right and left main bronchi and
corresponds with the upper border of the atria of the heart
Question:
Where do you palpate on the chest?
Answer:
Palpate the base, left sternal border and apex Mid-clavicular line, 5th intercostal space,
palpate PMI with one finger (located under breast tissue in women) assess location of
PMI (point of maximal impulse or apical impulse)
, Question:
Order of auscultation of the heart.
Answer:
A- aortic P - pulmonic T - tricuspid E - erbs point M - mitral 22345 Second ICS R of
sternum Second ICS L of sternum Third ICS L of sternum Fourth ICS L of sternum Fifth
ICS mid clavicular
Question:
Use of the Stethoscope:
-diaphragm -bell
Answer:
Diaphragm -High pitched sounds -Best for hearing S1 and S2 -(bowel, breath, normal
cardiac) Bell -Low pitched sounds -Use for hearing S3 and S4 -Use to assess for carotid
bruits -heart murmurs
Question:
Order of blood flow through the heart
Answer:
right atrium > tricuspid > right ventricle > pulmonary semilunar valve > pulmonary
veins > left atrium > mitral /bicuspid > left ventricle > aortic semilunar valve
Question:
Cardiac Cycle sounds:
-S1 -S2
Answer:
Systole -Heart sound = S1 - lub -Contraction and emptying of the atria and ventricles
-Aortic and pulmonic valves open -mitral and tricuspid valves close -S1 loudest at apex
Diastole -Heart sound = S2 - dub -Relaxation and filling of the atria and ventricles
-Aortic and pulmonic valves close -Mitral and tricuspid valves open -S2 loudest at base
Question:
Extra heart sounds:
S3 & S4
Answer:
S3... Due to Rapid ventricular filling: ventricular gallop S1 -- S2-S3 (Ken--tuc-ky) -Low
frequency sound in early diastole S4... Due to slow ventricular contraction: atrial gallop
S4-S1 - S2 (Ten-nes-see) -Low frequency sound in presystolic portion of diastole
Question:
S3 Heart Sound is resulted from what?
Answer:
Results from increased atrial pressure leading to increased flow rates, as seen in
congestive heart failure, which is the most common cause of a S3. Associated dilated
cardiomyopathy with dilated ventricles also contribute to the sound. Less commonly,
valvular regurgitation and left to right shunts may also result in a S3 due to increased
flow. May be normal physiological finding in patients less than age 40
