NURS 3320 Study guides, Class notes & Summaries

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NURS3320 Assessment Final Review Questions with Complete Solutions.

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What are the types of assessments? - ANSWER-Initial comprehensive Ongoing Focused Emergency Normal BP - ANSWER-120/80 Normal HR - ANSWER-60-100 bpm Normal RR - ANSWER-10-20 bpm, usually 1:4 with HR Normal SpO2 - ANSWER->97% Normal oral temperature - ANSWER-96-99.5F (35.8-37.3C) Normal axillary temperature - ANSWER-1 degree Celsius lower than oral Normal TM temperature - ANSWER-0.3-0.6 degrees Celsius higher than oral Normal rectal temperature - ANSWER-1 degree Celsi...

A pigskin-like or orange-peel (peau d'orange) appearance results from edema R/T lymphatic drainage, which is seen in - ANSWER-metastatic breast disease Normal superficial venous pattern - ANSWER-Veins radiate either horizontally and toward the axilla (transverse) or vertically with a lateral flare (longitudinal). Veins are more prominent during pregnancy. Peau d'orange skin, associated with carcinoma, may be first seen in the - ANSWER-areola Paget's disease - ANSWER-red, scaly, crust...

What should the nurse observe when assessing gait? - ANSWER-• Base of support • Weight-bearing stability • Foot position • Stride, length, and cadence of stride • Arm swing • Posture What should the nurse observe when assessing posture - ANSWER-the client's posture while standing with the feet together, noting alignment of the head, trunk, pelvis, and extremities. Also observe client's posture while sitting. Abnormal gait findings - ANSWER-Uneven weight bearing is eviden...

In which clients would you expect to see gynecomastia? - ANSWER-Males during puberty. Can also be seen in males with hormonal imbalance, drug abuse, cirrhosis, leukemia, and thyrotoxicosis Objective signs of breast cancer - ANSWER-Prominent/asymmetric venous pattern Pue d'orange skin Retracted nipple Dimpling Restricted movement of breast tissue Thickening of breast tissue Pain Discharge Large/irregular, hard, fixed nodules Normal variations in breast findings - ANSWER-nodes palpa...

A nurse is preparing to asses a client who is new to the clinic. When beginning the collection of the client database, which of the following actions should the nurse prioritize? - ANSWER-Establish a trusting relationship A nurse is interpreting and validating information from an older adult client who has been experiencing a functional decline. The nurse is in which phase of the interview? - ANSWER-Working A 71-year-old woman has been admitted to the hospital for a vaginal hysterectomy, a...

FIXED and non movalbe nodes are _________. - ANSWER-Malignant, tender and non movable Heart goes from ___ ICS to the ___ ICS - ANSWER-2nd ICS (base) to the 5th ICS (apex) Pericardium - ANSWER-Outer, double walled, sac w/ Fluid Myocardium - ANSWER-middle muscle layer, muscle=contraction Endocardium - ANSWER-inner, thin layer AV valves include the _________ valves & the ________ valves. - ANSWER-Tricuspid (R) valves & the Bicuspid (L) valves. T/F The AV Valves are the Entrance v...

What are the types of assessments? - ANSWER-Initial comprehensive Ongoing Focused Emergency Normal BP - ANSWER-120/80 Normal HR - ANSWER-60-100 bpm Normal RR - ANSWER-10-20 bpm, usually 1:4 with HR Normal SpO2 - ANSWER->97% Normal oral temperature - ANSWER-96-99.5F (35.8-37.3C) Normal axillary temperature - ANSWER-1 degree Celsius lower than oral Normal TM temperature - ANSWER-0.3-0.6 degrees Celsius higher than oral Normal rectal temperature - ANSWER-1 degree Celsi...