Nurs. 258 Final Exam with verified correct questions and answers

Nurs. 258 Final Exam Order of physical assessment skills - correct answer inspection, palpation, (percussion), auscultation Frequency of VS - correct answer MD orders, critical situations, after surgery, during blood transfusions, changes in pt status Factors that affect temperature - correct answer age, exercise, hormone changes, circadian rhythm, stress, environment, illness and injury Apical pulse location - correct answer 5th intercostal space, left mid-clavicular line Why might you take an apical pulse? - correct answer most accurate and when pt is on cardiac meds Factors the influence pulse - correct answer exercise, temperature, emotions, meds, hemorrhage, postural changes Factors affecting respirations - correct answer exercise, acute pain, anxiety, smoking, body position, medications, neurological injury, hemoglobin function Alterations in breathing pattern - correct answer bradypnea, tachypnea, hyperpnea, apnea, hyperventilation, hypoventilation Factors affecting BP - correct answer age, stress, ethnicity (AA men higher BP), meds, activity, weight, smoking How much change in BP would indicate orthostatic hypotension? - correct answer drop in 20 mmHg systolic How would you estimate systolic BP? - correct answer 1. palpate radial pulse 2. inflate cuff until pulse disappears 3. deflate cuff slowly 4. record mmHg where pulse reappears When should the nurse start checking BP on children? - correct answer not until at least 3 years old When assessing children specifically for mental status what area's should the nurse check? - correct answer head control, motor development, sensory development (7-9 months fully developed), Babinski reflex (children fan toes, adults flex feet and toes) LOC: alert - correct answer Awake or readily aroused, oriented, fully aware of external and internal stimuli and responds appropriately