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Nur 245 / Nur245 Exam 1. Questions With 100% Correct Answers.

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palpation applies sense of touch to assess -texture, temp. moisture, organ location and size, swelling/vibration, rigidity, creation, presence of lumps or masses -avoid any situation where palpation could cause internal injury or pain Percussion tapping persons skin with short, sharp stroke to assess underlying structures -direct: striking hand directly contacts body wall -indirect: using both hands the striking hand contacts stationary hand fixed on persons skin Auscultation listening to sounds of the body using stethoscope Health literacy understanding and following directions that lead to effective communication between the patient and the healthcare provider Neuropathic pain abnormal processing of pain message -types: diabetes, herpes, shingles, HIV/AIDs etc. Visceral pain originates from larger interior organs ex. kidney or stomach Deep somatic pain comes from sources such as blood vessels, joints, tendons, muscles, and bone Cutaneous pain derived from skin surface and subcutaneous tissues; injury is superficial with sharp, burning sensation Psychogenic pain linking pain to mental disorder referred pain felt at a particular site but originates from another location PQRST for pain P: provocative or palliative what makes it better or worse? Q: quality or quantity what is it like? R: region or radiation where is it? S: severity how bad is it? T:timing when did it start? McGill Pain Questionnaire asks patient to rank list of descriptors in terms of their intensity rating to his or her pain Acute pain behaviors guarding, grimacing, moaning, restlessness, stillness Systolic pressure max pressure felt on artery during left ventricular contraction diastolic pressure elastic recoil, or resting pressure that blood exerts constantly between each contraction auscultation listening to sounds produced by the body A complete health history includes all of the following: a. functional assessment b. review of systems c. physical assessment d. family history For older postoperative patients, poorly controlled acute pain places them at a higher risk for: a. atelectasis b. increased myocardial oxygen demand c. impaired wound healing d. all of the above 30-yr old women reports having persistent intense pain in her right arm related to trauma sustained from a car accident 5 months ago. she states that the slightest touch or clothing can exacerbate the pain. this report is suggestive of: a. referred pain b. psychogenic pain c. complex regional pain 1 d. cutaneous pain -a chronic progressive nerve condition characterized by burning, pain, swelling, stiffness, and discoloration of the affected extremity -key feature is brush of cotton ball or clothing that can cause a severe intense painful response CRIES is an appropriate assessment tool for: a. cognitively impaired older adults b. children ages 2-8 c. infants and children d. preterm and neonates Pain in the aging adult is considered to be: a. part of the normal degenerative process b. perceived to a lesser degree c. an expected finding d. unrelated to the aging process d. unrelated to the aging process Which is considered a common physiological change that occurs with pain? a. polyuria b. hyperventilation c. hyperactive bowel sounds d. tachycardia A patient is requesting pain medication and expresses a pain level of 9/10; however, the patient is up and smiling. how should you proceed? a. complete a full physical exam b. reposition patient but withhold pain medication based on behavior c. call the provider and suggest a substance abuse consult d. use therapeutic communication techniques to determine the patients pain scale goal and history of chronic pain

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NUR 245 EXAM 1
The concept of health and healing has evolved in recent years. Which is the best
description of health?
a. health is the absence of disease
b. health is a dynamic process toward optimal functioning
c. health depends on an interaction of mind, body, and spirit within environment
d. health is the prevention of disease




Which would be included in the database for a new patient admission to a surgical
unit?
a. all subjective and objective data gathered by a health practitioner from a patient
b. all objective data obtained from a patient through inspection, percussion,
palpation, and auscultation
c. a summary of a patients record, including laboratory studies
d. all subjective and objective data gathered from a patient, and the results of any
laboratory or diagnostic studies completed

,You are reviewing assessment data of a 45-yr old male patient and note pain of 8 on a
scale of 10, labored breathing, and pale skin color on the electronic health record.
This documentation is an example of:
a. hypothetical reasoning
b. diagnostic reasoning
c. data. cluster
d. signs and symptoms




A patient is is the emergency department with nausea and vomiting. which would you
include in the database?
a. a complete health history and full physical exam
b. diet and GI history
c. previously identified problems
d. start collection of data in conjunction with lifesaving measures




A patient has recently received health insurance and would like to know how often he
should visit the provider. How do you respond
a. "it would be most efficient if you visit on an annual basis"
b. "there is no recommendation for the frequency of health care visits."
c. "your visits may vary, depending on your level of wellness."
D. "You visits will be based on your preference."

,You are reviewing concepts related to steps in the nursing process for determining
prioritization and developing patient outcomes. To what are these actions attributed?
a. planning
b. assessment
c. implementation
d. diagnosis




What does the nursing process ADPIE stand for?
A: assessment
D: diagnosis
P: planning
I: implementation
E: evaluation




Nursing process assessment
collect data:
review clinical record

, health history
physical exam
functional assessment
risk assessment
review of the literature
-use evidence based techniques
-document relative data




Nursing process Diagnosis
compare clinical findings with normal and abnormal variation and developmental
events
Interpret data:
-identify clusters of clues
-make hypothesis
-test hypothesis
-derrive diagnosis
-validate diagnosis
-document diagnosis




Nursing process planning
-establish priorities

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