NSE 103 FINAL EXAM PREP
QUESTIONS WITH 100% VERIFIED
ANSWERS
what priority of care is associated with the abdomen? what should you do? - Answer-
signs associated with intestinal blockage - may need surgery
notify the physician after performing a primary survey & full abdominal assessment
only document the absence of bowl sounds after __________ - Answer-listening in
each quadrant for 5 minutes
what are some common causes of absent bowel sounds? - Answer-peritonitis
complete bowel obstruction
perforation of small/large intestine
what are normoactive bowel sounds? - Answer-5-30 sounds per minute - about 2
sounds every 5 seconds
what are hypoactive bowel sounds? what does it indicate? - Answer-less than 5 bowel
sounds per minute
indicates that intestinal activity has slowed
what are hyperactive bowel sounds? what does it indicate? - Answer-more than 30
bowel sounds per minute
indicates intestinal activity is quicker than normal
what conditions may cause hyperactive bowel sounds? - Answer-if a client has just
eaten
diahrrea
early/partial obstruction
bowel sound ______ is less important than ______ and _____ - Answer-quality is less
important than presence & frequency
,if a client is ticklish when palpating their abdomen, what should you do? - Answer-use a
"sandwich technique" - put their hand on top of your palpating hand, and your other
hand over top of both
what is rigidity? - Answer-involuntary firmness/hardness of the muscles?
what is rigidity of the abdomen associated with? - Answer-peritoneal inflammation
what are the signs of appendicitis? - Answer-increasing level of pain in the right lower
quadrant
lack of appetite
nausea
vomiting
fever
chills
muscle rigidity
where is the perianal region? - Answer-extends about 5cm around the anal opening
how should you position a patient during a perianal inspection/palpation? - Answer-
depends on clients preference/age
toddlers can be supine with legs up
older clients can either be in a left lateral position, lithotomy position, leaning over a
table with toes pointing inward, etc
what is the lithotomy position? - Answer-lying flat on the table with buttocks at the end of
the table and feet resting in stirrups
when inspecting the perianal region, what are you looking for? - Answer-colour
lesions or lumps
discharge
anal tone
how do you test for anal tone? - Answer-ask the client to contract or "draw in" their anus
can also be done by touching a cotton ball just lateral from the anus
when is anal tone important to assess? - Answer-for older clients or other clients who
have indicated problems with fecal incontinence
what health promotion categories are associated with the gastrointestinal system? -
Answer-hand hygiene
mouth & dental care
,diet
smoking
alcohol
cannabis
activity
what is hypoxemia? - Answer-low oxygen in the blood
what is hypoxia? - Answer-lack of oxygen in tissues & organs
what does cardiac pain feel like? - Answer-crushing, pressure, squeezing, tightness,
heaviness
where is cardiac pain felt? - Answer-chest
jaw
neck
arms(especially the left)
upper back
abdomen
cardiac pain is a _____ finding, meaning it requires ___________ - Answer-critical
immediate action
what is nitroglycerin? - Answer-a medication that acts to dilate/expand blood vessels so
oxygenated blood is more easily perfused to the heart muscle, reducing cardiac pain
what is dyspnea? - Answer-shortness of breath
what can you do to help someone with dyspnea? - Answer-raise the head of the bed
if someone presents with dyspnea, what should you assess? - Answer-all standard
vitals + auscultate the lungs
what are arrhythmias? what do they feel like? - Answer-irregular heart rhythms
may feel like the heart is skipping a beat or fluttering
if someone presents with arrhythmias & you are concerned about clinical deterioration,
what should you do? - Answer-conduct a primary survey
__________ are common symptoms of heart disease, because in people with heart
failure, their _____________ - Answer-coughing or wheezing
their blood can back up into their lungs, affecting breathing
, what is expectorate? - Answer-sputum from coughing
what is hemoptysis? - Answer-blood in sputum, coughing up blood
if someone has peripheral edema, you should assess if ______ - Answer-if the edema
is acute or chronic, and unilateral or bilateral
if peripheral edema is acute & unilateral, it may be __________ or ________ - Answer-
DVT or an injury
if peripheral edema is chronic & bilateral, it is more likely to be a ___________ -
Answer-systemic issue with the heart
__________ and edema are often related - Answer-nocturia/rapid weight gain
what is diaphoresis? - Answer-excessive sweating
what priorities of care are related to cardiac symptoms? - Answer-chest pain may signify
angina - could cause a heart attack
or a hypertensive crisis - could lead to myocardial infarction or stroke
what is a hypertensive crisis? - Answer-BP higher than 180 and/or higher than 120
how should you approach assessing the chest of someone wearing a binder? - Answer-
ask non-judgemental questions
explain, ask if they have questions
assess binder for proper fit
bruits heard in the carotid arteries may indicate______, which is ________ - Answer-
carotid stenosis, narrowing of the carotid artery
what is the normal findings when assessing the carotid arteries? - Answer-"2+ carotid
pulsation equal bilaterally, smooth contour with a quick upstroke and gradual
downstroke."
assessment of the jugular veins provides information on __________ - Answer-the
central venous pressure, fluid status & functioning of right ventricle
distention of the jugular veins indicates: - Answer-elevated central venous pressure -
may be indicative of fluid retention
QUESTIONS WITH 100% VERIFIED
ANSWERS
what priority of care is associated with the abdomen? what should you do? - Answer-
signs associated with intestinal blockage - may need surgery
notify the physician after performing a primary survey & full abdominal assessment
only document the absence of bowl sounds after __________ - Answer-listening in
each quadrant for 5 minutes
what are some common causes of absent bowel sounds? - Answer-peritonitis
complete bowel obstruction
perforation of small/large intestine
what are normoactive bowel sounds? - Answer-5-30 sounds per minute - about 2
sounds every 5 seconds
what are hypoactive bowel sounds? what does it indicate? - Answer-less than 5 bowel
sounds per minute
indicates that intestinal activity has slowed
what are hyperactive bowel sounds? what does it indicate? - Answer-more than 30
bowel sounds per minute
indicates intestinal activity is quicker than normal
what conditions may cause hyperactive bowel sounds? - Answer-if a client has just
eaten
diahrrea
early/partial obstruction
bowel sound ______ is less important than ______ and _____ - Answer-quality is less
important than presence & frequency
,if a client is ticklish when palpating their abdomen, what should you do? - Answer-use a
"sandwich technique" - put their hand on top of your palpating hand, and your other
hand over top of both
what is rigidity? - Answer-involuntary firmness/hardness of the muscles?
what is rigidity of the abdomen associated with? - Answer-peritoneal inflammation
what are the signs of appendicitis? - Answer-increasing level of pain in the right lower
quadrant
lack of appetite
nausea
vomiting
fever
chills
muscle rigidity
where is the perianal region? - Answer-extends about 5cm around the anal opening
how should you position a patient during a perianal inspection/palpation? - Answer-
depends on clients preference/age
toddlers can be supine with legs up
older clients can either be in a left lateral position, lithotomy position, leaning over a
table with toes pointing inward, etc
what is the lithotomy position? - Answer-lying flat on the table with buttocks at the end of
the table and feet resting in stirrups
when inspecting the perianal region, what are you looking for? - Answer-colour
lesions or lumps
discharge
anal tone
how do you test for anal tone? - Answer-ask the client to contract or "draw in" their anus
can also be done by touching a cotton ball just lateral from the anus
when is anal tone important to assess? - Answer-for older clients or other clients who
have indicated problems with fecal incontinence
what health promotion categories are associated with the gastrointestinal system? -
Answer-hand hygiene
mouth & dental care
,diet
smoking
alcohol
cannabis
activity
what is hypoxemia? - Answer-low oxygen in the blood
what is hypoxia? - Answer-lack of oxygen in tissues & organs
what does cardiac pain feel like? - Answer-crushing, pressure, squeezing, tightness,
heaviness
where is cardiac pain felt? - Answer-chest
jaw
neck
arms(especially the left)
upper back
abdomen
cardiac pain is a _____ finding, meaning it requires ___________ - Answer-critical
immediate action
what is nitroglycerin? - Answer-a medication that acts to dilate/expand blood vessels so
oxygenated blood is more easily perfused to the heart muscle, reducing cardiac pain
what is dyspnea? - Answer-shortness of breath
what can you do to help someone with dyspnea? - Answer-raise the head of the bed
if someone presents with dyspnea, what should you assess? - Answer-all standard
vitals + auscultate the lungs
what are arrhythmias? what do they feel like? - Answer-irregular heart rhythms
may feel like the heart is skipping a beat or fluttering
if someone presents with arrhythmias & you are concerned about clinical deterioration,
what should you do? - Answer-conduct a primary survey
__________ are common symptoms of heart disease, because in people with heart
failure, their _____________ - Answer-coughing or wheezing
their blood can back up into their lungs, affecting breathing
, what is expectorate? - Answer-sputum from coughing
what is hemoptysis? - Answer-blood in sputum, coughing up blood
if someone has peripheral edema, you should assess if ______ - Answer-if the edema
is acute or chronic, and unilateral or bilateral
if peripheral edema is acute & unilateral, it may be __________ or ________ - Answer-
DVT or an injury
if peripheral edema is chronic & bilateral, it is more likely to be a ___________ -
Answer-systemic issue with the heart
__________ and edema are often related - Answer-nocturia/rapid weight gain
what is diaphoresis? - Answer-excessive sweating
what priorities of care are related to cardiac symptoms? - Answer-chest pain may signify
angina - could cause a heart attack
or a hypertensive crisis - could lead to myocardial infarction or stroke
what is a hypertensive crisis? - Answer-BP higher than 180 and/or higher than 120
how should you approach assessing the chest of someone wearing a binder? - Answer-
ask non-judgemental questions
explain, ask if they have questions
assess binder for proper fit
bruits heard in the carotid arteries may indicate______, which is ________ - Answer-
carotid stenosis, narrowing of the carotid artery
what is the normal findings when assessing the carotid arteries? - Answer-"2+ carotid
pulsation equal bilaterally, smooth contour with a quick upstroke and gradual
downstroke."
assessment of the jugular veins provides information on __________ - Answer-the
central venous pressure, fluid status & functioning of right ventricle
distention of the jugular veins indicates: - Answer-elevated central venous pressure -
may be indicative of fluid retention
