NU 305 Final Exam Study Guide
Abdominal Aorta Assessment Correct Answers - Blood to
lower part of body
- Lightly palpate; listen for vascular sounds that indicate bruits
(turbulent blood flow (may be aneurysm)
- Indications that tell you to auscultate for Bruit = Peripheral
pulses diminished, cool limb(s), pulsations
Active Listening Correct Answers - Ability to focus on pt's &
their perspectives
Activity Intolerance Correct Answers - Assess Charac = Report
of pain or claudication, Fatigue, Weakness
- Nu Interv = Gradually increase activity, Refer to therapy or
rehab, Allow periods of rest before & after activity
Activity Intolerance Nu Dx Correct Answers - Assess Charac =
Dyspneic with minimal activity, SaO2 decreases & RR increases
with activity
- Nu Interv = Teach energy-conserving measures, Evaluate need
for supplemental O2, Teach slow & steady walking with gradual
increase in distance
Activity Intolerance Nu Dx Correct Answers - Assess Charac =
Report of fatigue or weakness, Abnormal pulse or BP, SOB,
Dizziness, Chest pain
- Nu Interv = Determine cause of intolerance, Promote
reconditioning when the result of immobility, Gradually increase
activity according to symptoms
,Acute Confusion Nu Dx Correct Answers - Asses Charac =
Fluctuation in cognition, Increased agitation or restlessness,
Lack of follow-through in behavior
- Nu Interv = Perofrm mental status exam, Provide
environmental cues, Orient to time, place, & person frequently
Appropriate techniques of Lung Auscultation Correct Answers
- Listen for a full breath
- Scope to skin
- 4 Anterior
- 2 Lateral
- 6 Posterior
- Start at top & move down (comparing sides)
Assessing Level of Consciousness Correct Answers - GSC
- Eye, motor & verbal response
Blood Flow through Heart Correct Answers - Sup/Inf Vena
Cava - R Atrium - Tricuspid Valve - R Ventricle - Pulmonic
Valve - Pulmonary Trunk - Pulmonary Arteries - LUNGS
- Pulmonary Veins - L Atrium - Mitral Valve - L Ventricle -
Aortic Valve - BODY
Blumberg Sign Correct Answers - Assessment technique
elicited during abdominal assessment to check for Peritonitis
- Checks rebound tenderness
- In a site away from painful area, push down slowly & deeply
then lift quickly
Brawny Correct Answers - Dark, leathery appearance
- Indication of CVI
, Bronchial Breath Sound Correct Answers - Loud & high-
pitched
- Larynx & trachea
Bronchovesicular Breath Sound Correct Answers - More
centrally located over bronchi with fewer alveoli
Carotid Evaluation Correct Answers - Listen with bell
- Never palpate at same time
Clarification Correct Answers - When pt's words are unclear
- The nurse can restate the basic message or confess confusion
and ask the client to repeat or restate the message
Closing Interview Correct Answers - A conversation at the end
of an evaluation session in which the clinician informs the client
or family of her findings, makes recommendations for the
future, and elicits questions
- Summarizing/stating 2-3 most important problems
- Let pt know next steps & thank pt/family
- Save most invasive/ embarrassing procedure for last
Comprehensive Exam Correct Answers - Includes
demographic data, full description of reason for seeking care,
individual health history, family history, functional status, &
history in all physical/psychosocial areas
- Occurs on admission & physical exams
Constipation Nu Dx Correct Answers - Assess Charac = Abd.
distention, Pain, Tenderness, Firm abd, No stool for days
Abdominal Aorta Assessment Correct Answers - Blood to
lower part of body
- Lightly palpate; listen for vascular sounds that indicate bruits
(turbulent blood flow (may be aneurysm)
- Indications that tell you to auscultate for Bruit = Peripheral
pulses diminished, cool limb(s), pulsations
Active Listening Correct Answers - Ability to focus on pt's &
their perspectives
Activity Intolerance Correct Answers - Assess Charac = Report
of pain or claudication, Fatigue, Weakness
- Nu Interv = Gradually increase activity, Refer to therapy or
rehab, Allow periods of rest before & after activity
Activity Intolerance Nu Dx Correct Answers - Assess Charac =
Dyspneic with minimal activity, SaO2 decreases & RR increases
with activity
- Nu Interv = Teach energy-conserving measures, Evaluate need
for supplemental O2, Teach slow & steady walking with gradual
increase in distance
Activity Intolerance Nu Dx Correct Answers - Assess Charac =
Report of fatigue or weakness, Abnormal pulse or BP, SOB,
Dizziness, Chest pain
- Nu Interv = Determine cause of intolerance, Promote
reconditioning when the result of immobility, Gradually increase
activity according to symptoms
,Acute Confusion Nu Dx Correct Answers - Asses Charac =
Fluctuation in cognition, Increased agitation or restlessness,
Lack of follow-through in behavior
- Nu Interv = Perofrm mental status exam, Provide
environmental cues, Orient to time, place, & person frequently
Appropriate techniques of Lung Auscultation Correct Answers
- Listen for a full breath
- Scope to skin
- 4 Anterior
- 2 Lateral
- 6 Posterior
- Start at top & move down (comparing sides)
Assessing Level of Consciousness Correct Answers - GSC
- Eye, motor & verbal response
Blood Flow through Heart Correct Answers - Sup/Inf Vena
Cava - R Atrium - Tricuspid Valve - R Ventricle - Pulmonic
Valve - Pulmonary Trunk - Pulmonary Arteries - LUNGS
- Pulmonary Veins - L Atrium - Mitral Valve - L Ventricle -
Aortic Valve - BODY
Blumberg Sign Correct Answers - Assessment technique
elicited during abdominal assessment to check for Peritonitis
- Checks rebound tenderness
- In a site away from painful area, push down slowly & deeply
then lift quickly
Brawny Correct Answers - Dark, leathery appearance
- Indication of CVI
, Bronchial Breath Sound Correct Answers - Loud & high-
pitched
- Larynx & trachea
Bronchovesicular Breath Sound Correct Answers - More
centrally located over bronchi with fewer alveoli
Carotid Evaluation Correct Answers - Listen with bell
- Never palpate at same time
Clarification Correct Answers - When pt's words are unclear
- The nurse can restate the basic message or confess confusion
and ask the client to repeat or restate the message
Closing Interview Correct Answers - A conversation at the end
of an evaluation session in which the clinician informs the client
or family of her findings, makes recommendations for the
future, and elicits questions
- Summarizing/stating 2-3 most important problems
- Let pt know next steps & thank pt/family
- Save most invasive/ embarrassing procedure for last
Comprehensive Exam Correct Answers - Includes
demographic data, full description of reason for seeking care,
individual health history, family history, functional status, &
history in all physical/psychosocial areas
- Occurs on admission & physical exams
Constipation Nu Dx Correct Answers - Assess Charac = Abd.
distention, Pain, Tenderness, Firm abd, No stool for days
