exam//verified Questions and
Answers//Latest version!!
nursing process ✔️✔️correct answer-assess
diagnose
outcome/planning
implement
evaluate
techniques of physical assessment ✔️✔️correct answer-inspection
palpation
percussion
auscultation
start physical assessment with ✔️✔️correct answer-general survey assess for
-appearance
-behavior
-height/weight/BMI
-nutritional status
-waist circumference which can indicate obesity
when assessing the integumentary system you are looking for ✔️✔️correct answer-
erythema - indicating fever/inflammation
cyanosis - indicating O2 loss
jaundice - ^ billiruben
pallor - low on blood
ecchymosis
petechiae
lesions
integumentary assessment ✔️✔️correct answer-palpate for temperature, moisture,
turgor, edema
and inspect
adventitious breath sounds ✔️✔️correct answer-wheeze - high pitch indicating airway
obstruction
crackles - bubbling on in/ex
stridor - harsh high pitch sound on inhale
ronchi - sonourus , coarse low pitch
friction rub
,extra heart sounds ✔️✔️correct answer-s3-normal in children
s4- normal in older adults
order to listen to heart sounds ✔️✔️correct answer-APETM
aortic, pulmonic, erbs point, tricuspid, mitral
assessing the abdomen what order ✔️✔️correct answer-inspect
auscultate
percussion
palpate
when to assess VS ✔️✔️correct answer-on admission
based on policy
with CHANGE in condition
loss of consciousness
before/after invasive procedure
before/after med admin
heat production measures the body takes ✔️✔️correct answer-shivering
piloerection
vasoconstriction
increased metabolism
heat losing measures the body takes ✔️✔️correct answer-sweating
vasodilation
increased respirations
jellinek curve ✔️✔️correct answer-phase 1 - pre alcoholic - using to relieve every day
stress
phase 2 - early alcoholic - blackouts/needs it, secretive about it gulps 1st drink
phase 3 - crucial phase - lost control and gets defensive
phase 4 - chronic phase -
greatest risk for seizures in alcohol withdrawal is ✔️✔️correct answer-within 7-48
hours of last drink
bowel sounds should occur ✔️✔️correct answer-every 5-35 seconds
gurgling
if no sounds for 5 minutes = silent ileus
bruits ✔️✔️correct answer-abnormal bowel sound auscultated during abdominal
assessment sounds like a swishing noise and indicates obstruction
neurovascular assessment ✔️✔️correct answer-6 P's
, 1. pain
2. pallor
3. peripheral pulses
4. paresthesia
5. paralysis
6. pressure
cranial nerve 5 ✔️✔️correct answer-trigeminal
-motor/sensation
CHEWING
cranial nerve 7 ✔️✔️correct answer-facial
SMILE
cranial nerve 9 ✔️✔️correct answer-glossopharyngeal
SWALLOWING
cranial nerve 12 ✔️✔️correct answer-tongue
STICK YOUR TONGUE OUT AT ME
CIWA-AR ✔️✔️correct answer-monitors pt response to tx; determines need for
medication, prevents seizures. use ciwa-ar every 2 hours then 4 hours
alcoholism medications that promote sobriety ✔️✔️correct answer-- Disulfiram
(antabuse) - causes severe neg. reaction to alcohol can lead to death even if only
around paint fumes.
-Naltrexone (ReVia) - reduces cravings by blocking the effects of alcohol PRN or
monthly inj.
-acamprosate (campral) - reduces want/craving can't be used for pt with renal failure (2
tab 3x/day)
3 groups of laxatives and their functions ✔️✔️correct answer-1. chemical laxatives
(stimulate/irritate lining of GI
2. bulk laxatives (causes feces to ^ in bulk by ^ water content)
3. lubricant (move more smoothly)
medications that cause diarrhea ✔️✔️correct answer-antibiotics
magnesium
medications that cause constipation ✔️✔️correct answer-opioids
antacids
iron sulfate
anticholinergics
GI bleed stool will be ✔️✔️correct answer-black if bleed is high in GI tract