NR 302

The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment of the client, the nurse should expect to note which finding? 1. Increasing rate and depth of respirations with periods of apnea 2. Regular rapid and deep, sustained respirations 3. Totally irregular respiration in rhythm and depth 4. Irregular respirations with pauses at the end of inspiration and expiration Correct Answer: 1. Increasing rate and depth of respirations with periods of apne...

The retinal structures viewed through the ophthalmoscope are: Correct Answer: optic disc, vessels, macula, background "Positive consensual light reflex" means... Correct Answer: simultaneous constriction The thickening and yellowing of the lens due to aging is described as: Correct Answer: cataract Eye emergency Correct Answer: sudden change in vision Visual acuity is assessed with: Correct Answer: Snellen eye chart The cover test is used to assess for: Correct Answer: mus...

Wheezing breath sounds Correct Answer: musical sound crackles or rales Correct Answer: bubbling sounds dysphegia Correct Answer: difficulty swallowing disphesia Correct Answer: speech, difficulty speaking or taking Ptosis Correct Answer: 6 Drooping upper lid What is subjective data? Correct Answer: -Data that only the subject or "patient" can feel and will tell you. Usually in a statement. -eg nausea, constipation, dizziness, palpation, numbness, PAIN, difficulty breathin...

Actual Dx Correct Answer: Actual Diagnosis related to (R/T) ________(Related Factors) as evidenced by (AEB) ________ (Defining Characteristics) Risk Correct Answer: Risk for __________as evidenced by _________ (Risk Factors). Readiness Correct Answer: Readiness for __________as evidenced by "_________" (Defining characteristics). Asthma Correct Answer: chronic hyper-reactive condition. Obstruction. Wheezing. Dyspnea, increased RR, use of accessory muscles, anxiety, prolonged expir...

erythema white skin is redness of the skin produced by capillary congestion objective data measurable data, for example vital signs after completing an initial assessment on a pt, the nurse charts, vital signs as temp of 100.1 oral, apical HR 98 irregular, RR 24 shallow, B/P 128/90, pulse ox of 90% on RA, what are you worried about oxygenation, infection, activity intolerance, capillary refill greater than 3 seconds during assessment of the lower extremities of a male pat...

NR302 Final Exam Study Guide: Health Assessment I: Chamberlain Thorax and Lungs -What data can be gathered on a patient in respiratory distress from general survey only? -Do they use accessory muscles when breathing? Position-tripod, Barrel chest, Nasal flaring, color -Structure and Function: The thorax -Thoracic cage -Sternum, 12 pairs of ribs -12 thoracic vertebrae -Muscles and cartilage -Thoracic Cavity -Mediastinium -Pleural cavity -Lung (Apex and base) Structure and Function: Pleural Membra...