NUR 2830 Final Review Questions And Answers With Verified Solutions Graded A+

4 assessment techniques - Inspection Palpation Percussion Auscultation ABC's - airway, breathing, circulation airway is most important Abnormal lung sounds - Rales = fluid in the bases (LA) Wheezing = bronchial constriction (LA) Rhonchi = large amount of secretion (midlung) Stridor = obstruction in (UA) Abnormal lymph nodes - large, tender, fixed, hard Abnormal skin findings - cool to touch hot to touch diaphoretic jaundice (yellow) cyanotic(blue) pallor urticaria (hives) petechiae/purpura Acute pain - pain that is felt suddenly from injury, disease, trauma, or surgeryArterial ulcers - Braden Scale - sensory perception, moisture, activity, mobility, nutrition, friction and shear Bruit - abnormal blowing or swishing sound heard during auscultation of an artery or organ Cardiac assessments - The cardiac examination consists of evaluation of (1) the carotid arterial pulse and auscultation for carotid bruits; (2) the jugular venous pulse and auscultation for cervical venous hums; (3) the precordial impulses and palpation for heart sounds and murmurs; and (4) auscultation of the heart. capillary refill venous patterns pulses edema Chronic pain - episode of pain that lasts for 6 months or longer; may be intermittent or continuous Coma - does not respond, does not speak Comprehensive assessment - health history and complete physical examination, usually conducted when a patient first enters a health care setting; provides a baseline for comparing later assessment DVT - deep vein thrombosis Edema grading - • 1+ Mild pitting, slight indentation, no perceptible swelling of the leg • 2+ Moderate pitting, indentation, subsides rapidly • 3+ Deep pitting, indentation remains for a short time, leg looks swollen • 4+ Very deep pitting, indentation lasts a long time, leg is very swollenFocused assessment - A type of physical assessment that is typically performed on patients who have sustained nonsignificant mechanisms of injury or on responsive medical patients. This type of examination is based on the chief complaint and focuses on one body system or part. Glascow Coma Scale - Severe 8 Moderate 9-12 Minor 13 Heart sounds - S1: d/t closure of mitral and tricuspid, blood hits them. "lub". louder when stethoscope is by mitral valve S2: when blood hits closed arotic/pulmonic valves. "dub" louder when stethoscope is by aortic valve sound 2 is loudest in space (ICS) 2 bruits: turbulent blood flow in artery. always bad unless AV fistula HPV signs and symptoms - Warts can be flat, raised, or lumpy. Cervical cancer has no early symptoms -pap Lethargy - sleeps frequently, wakes to voice or shake LOC (level of consciousness) - fully aware, confusion, lethargy, obtundation, stupor, coma Lung assessment - percussion: expected: resonance unexpected: dullness (tumor, pneumonia) hyperresonance: (pneumothorax, emphysema)auscultation: expected: bronchial (trachea), bronchovesicular (over large airways), vesicular (over peripheral areas of lungs) unexpected: crackles (bubbly sounds), wheezes (whistling, musical sounds), pleural friction rub (grating, rubbing sounds) Melanoma - ABCDE asymmetry, border, color, diameter and evolving Morse fall scale - Normal lymph nodes - movable, discrete, soft, and nontender Objective findings - what you observe or see Obtundation - Mild to moderate reduction in arousal (awakeness) with limited response to environment; falls asleep unless stimulated verbally or tactilely; answers questions with minimal response OLDCARTS - onset location duration characterists alleviates/aggregates radiates time scalePERRLA and EOM's - Pupils are equal, round, reactive to light, and accommodate EOM's in 6 cardinal fields of gaze Primary prevention - those preventive measures that come before the onset of illness or injury and before the disease process begins