1|Page
NR 304 FINAL EXAM TEST BANK ALL
QUESTIONS AND CORRECT DETAILED
ANSWERS ALREADY A+
What happens during the evaluation step of the nursing process? - ANSWER
Progress towards outcomes, use ongoing assessment to revise
diagnoses/outcomes/plans, disseminate results to patient and family
What happens during the diagnosis stage of the nursing process? - ANSWER
Compare clinical findings with normal and abnormal variation and developmental
events, interpret data, validate and document diagnoses.
What is a problem center database? Give an example. - ANSWER For limited or
short term problems. Collect mini/targeted databases. Focuses on only one
problem or body system and is used in all clinical settings.
Ex: two days post-op patient suddenly becomes SOB with congestive cough and
fatigue; focus on respiratory and cardiovascular systems
What are the components of a general survey? - ANSWER Begins during first
patient encounter.. Includes their physical appearance, body structure, mobility,
behavior, body measurements
What is the grading of pulse force? - ANSWER 3+ Full, bounding
2+ Normal
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1+ Weak, thready
0 Absent
What are causes of hypotension? - ANSWER Acute myocardial infarction, shock,
hemorrhage, vasodilation, Addison's disease
What is the blood pressure measurement for hypotension? - ANSWER Less than
95/60 mmHg
Acute myocardial infarction and shark causes a _____ cardiac output which leads
to hypertension? - ANSWER Decreased
Hemorrhage causes a _____ total blood volume that leads to hypotension -
ANSWER decreased
Vasodilation causes a ____peripheral vascular resistance that leads to
hypotension - ANSWER decreased
Addison's disease (hypofunction of adrenal gland) is caused by a ___ circulating
aldosterone which causes hypotension - ANSWER decreased
How do you count respirations? - ANSWER Count while assessing radial pulse to
make patient unaware that you were counting respirations. Count for 30 seconds
of normal or 1 minute if abnormal
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What are the effects of smoking on blood pressure? - ANSWER Vasoconstriction
of the arteries which makes your blood pressure increase. Long-term cause of
hypertension
What is the ABCDEF skin lesions mean? - ANSWER Asymmetry, border
irregularity, color variation, diameter greater than 6mm, elevation/evolution,
funny looking
What are the physiological changes associated with acute pain responses? -
ANSWER Tachycardia, elevated blood pressure, increased cardiac output,
hypoxia, hypoventilation, atelectasis, decreased cough, nausea, vomiting, ileus,
oliguria, urinary retention, spasm, joint stiffness, increased adrenergic activity,
fear, anxiety, fatigue, impaired immunity, wound healing
How do you assess for clubbing? - ANSWER Put nail beds back to back and view
profile sign index. Normal is 160°. Early clubbing is 180° and lake clubbing is
anything less than 160°
What patients does clubbing occur? - ANSWER Smoking, lung cancer, pulmonary
disease, congenital cyanotic heart disease
How do you detect pallor in a light skinned patient? - ANSWER Generalized pallor
How do you detect pallor in a dark skinned patient? - ANSWER Ashen gray, dull,
loss of glow, cool to palpation
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How do you detect jaundice in a light-skinned patient? - ANSWER Yellow sclera,
hard palate, skin, mucous membranes
How do you observe jaundice in a dark skinned patient? - ANSWER Observe the
palms, hard and soft palates
How do you observe cyanosis in a light skinned patient? - ANSWER Dusky blue
appearance
How do you observe cyanosis in a dark skinned patient? - ANSWER Dullness,
check conjunctiva, oral cavity, nails
How do you observe erythema in a light skin patient? - ANSWER Red or bright
pink color
How do you observe erythema in a dark skinned patient? - ANSWER Purpleish
tinge, difficult to observe, palpate for warmth
What is the name and characteristics of a stage one pressure injury? - ANSWER
Stage 1 non-blanchable erythema
Intact skin with a localized area of non-blanchable erythema
What is the name and characteristics of a stage 2 pressure injury? - ANSWER
Stage 2 partial thickness skin loss
NR 304 FINAL EXAM TEST BANK ALL
QUESTIONS AND CORRECT DETAILED
ANSWERS ALREADY A+
What happens during the evaluation step of the nursing process? - ANSWER
Progress towards outcomes, use ongoing assessment to revise
diagnoses/outcomes/plans, disseminate results to patient and family
What happens during the diagnosis stage of the nursing process? - ANSWER
Compare clinical findings with normal and abnormal variation and developmental
events, interpret data, validate and document diagnoses.
What is a problem center database? Give an example. - ANSWER For limited or
short term problems. Collect mini/targeted databases. Focuses on only one
problem or body system and is used in all clinical settings.
Ex: two days post-op patient suddenly becomes SOB with congestive cough and
fatigue; focus on respiratory and cardiovascular systems
What are the components of a general survey? - ANSWER Begins during first
patient encounter.. Includes their physical appearance, body structure, mobility,
behavior, body measurements
What is the grading of pulse force? - ANSWER 3+ Full, bounding
2+ Normal
,2|Page
1+ Weak, thready
0 Absent
What are causes of hypotension? - ANSWER Acute myocardial infarction, shock,
hemorrhage, vasodilation, Addison's disease
What is the blood pressure measurement for hypotension? - ANSWER Less than
95/60 mmHg
Acute myocardial infarction and shark causes a _____ cardiac output which leads
to hypertension? - ANSWER Decreased
Hemorrhage causes a _____ total blood volume that leads to hypotension -
ANSWER decreased
Vasodilation causes a ____peripheral vascular resistance that leads to
hypotension - ANSWER decreased
Addison's disease (hypofunction of adrenal gland) is caused by a ___ circulating
aldosterone which causes hypotension - ANSWER decreased
How do you count respirations? - ANSWER Count while assessing radial pulse to
make patient unaware that you were counting respirations. Count for 30 seconds
of normal or 1 minute if abnormal
,3|Page
What are the effects of smoking on blood pressure? - ANSWER Vasoconstriction
of the arteries which makes your blood pressure increase. Long-term cause of
hypertension
What is the ABCDEF skin lesions mean? - ANSWER Asymmetry, border
irregularity, color variation, diameter greater than 6mm, elevation/evolution,
funny looking
What are the physiological changes associated with acute pain responses? -
ANSWER Tachycardia, elevated blood pressure, increased cardiac output,
hypoxia, hypoventilation, atelectasis, decreased cough, nausea, vomiting, ileus,
oliguria, urinary retention, spasm, joint stiffness, increased adrenergic activity,
fear, anxiety, fatigue, impaired immunity, wound healing
How do you assess for clubbing? - ANSWER Put nail beds back to back and view
profile sign index. Normal is 160°. Early clubbing is 180° and lake clubbing is
anything less than 160°
What patients does clubbing occur? - ANSWER Smoking, lung cancer, pulmonary
disease, congenital cyanotic heart disease
How do you detect pallor in a light skinned patient? - ANSWER Generalized pallor
How do you detect pallor in a dark skinned patient? - ANSWER Ashen gray, dull,
loss of glow, cool to palpation
, 4|Page
How do you detect jaundice in a light-skinned patient? - ANSWER Yellow sclera,
hard palate, skin, mucous membranes
How do you observe jaundice in a dark skinned patient? - ANSWER Observe the
palms, hard and soft palates
How do you observe cyanosis in a light skinned patient? - ANSWER Dusky blue
appearance
How do you observe cyanosis in a dark skinned patient? - ANSWER Dullness,
check conjunctiva, oral cavity, nails
How do you observe erythema in a light skin patient? - ANSWER Red or bright
pink color
How do you observe erythema in a dark skinned patient? - ANSWER Purpleish
tinge, difficult to observe, palpate for warmth
What is the name and characteristics of a stage one pressure injury? - ANSWER
Stage 1 non-blanchable erythema
Intact skin with a localized area of non-blanchable erythema
What is the name and characteristics of a stage 2 pressure injury? - ANSWER
Stage 2 partial thickness skin loss
