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NUR 3094C/NUR3094 FINAL EXAM 2025
PRACTICE QUESTIONS VERSION 1 GRADED A+
(Verified Answers 100%)
The nurse is caring for patients on the surgical floor and has just received report from the previous shift. Which of the following patients should the nurse see FIRST? A. A 35 - year-old admitted three hours ago with a gunshot would; 1.5 cm area of dark drainage noted on the dressing B. A 43 - year-old who had a masectomy tow days ago; 23 cc of serosanguinous fluid noted in the Jackson-Pratt drain C. A 59-year-old with a collapsed lung due to an accident; no drainage noted in the previous eight hours D. A 62 - year-old who had an abdominal-perineal resection three days ago; patient complains of chills D The nurse is caring for patients in the outpatient clinic. Which of the following phone calls should the nurse return first? A. A client with hepatitis A who states "My arms and legs are itching." B. A client with a cast on the right leg who states, " I have a funny feeling in my right leg."
C. A client with osteomylitis of the spine who states, " I am so nauseous that I can't eat." D. A client with rheumatoid arthritis who states, " I am having trouble sleeping." B high priority Airway Breathing Circulaltion Vital Signs Second priority mental status change untreated medical problem acute pain acute urinary elimination problem abnormal lab value risk of infection cultural consideration hispanic Curanderos use herbs, aromas, and rituals to treat the ills of the body, mind and spirit. have a higher rate of diabetes
engaging in distancing using professional jargon using leading or biased questions talking too much interrupting using why questions this age uses telegraphic speech so it is best to keep explainations simple preschooler this age can tolerate and understand others viewpoints, more objective and realistic, able to reason very curious school age value peers, crave acceptance, think that no adult can understand them adolescent broca's aphsia can understand language but cannot express it himself nonfluent, dysarthic, effortful speech wernickes aphasia can hear sounds but cannot relate them to previous experiences speech is fluent, effortless and well articulated but has many paraphasias and made up words
subjective data "Lately I just don't feel like myself" objective data HR=80 BP=125/80 T=38 RR= skin feels cool, & clammy etc interpreter dont use family member must use trained medical interpreter nonverbal cross cultural vocal cues action cues object cues use of personal and territorial space touch nonverbal physical appearance posture
avoid elder speak allow more time for interview collect most important data first, allow for multiple meetings adjust pace; allow time to answer questions fully head/chest circumference infant Newborn's chest grows at a faster rate than the cranium; @ some point btw 6mths & 2 yrs, both measurements are about the same, & after 2 yrs of age the chest circumference is greater than the head circumference. Enlarged head circumference occurs w/ increased ICP radial pulse p. 0 absent 1+ weak( as with shock and peripheral arterial disease) 2+ normal 3+ increased/full/bounding (as with anxiety, exercise, fever, anemia, hyperthyroidism) eczema atopic dermatitis erythematous papules and vesicles with weeping oozing and crusts lesiosn usually on scalp forehead cheeks forearms and wrists elbows backs on knees family history of allergie impetigo moist thin roofed vesciles with thin erythemous base. rupture to form HONEY COLORED CRUST contagious bacterial infection of the skin most common in infants and children
dermatitis an inflammation of the skin characterized by redness, pruitus (itching), and various lesions herpes zoster small grouped vesicles emerge along route of a cutaneous sensory nerve, then pustules then crusts. caused by the varicella zoster virus acute appearance UNILATERAL DOES NOT CROSS MIDLINE trichtillomania traumatic self induced hair loss usually the result of compulsive teisting or plucking forms irregularly shaped patch, with broken off stublike hairs of varying lengths; person is never completely bald occurs as child rubs or twists area absently while falling asleep reading or watching tv in adults it is a sign of a serious personality disorder folliculitis superficial infection of hair follicles multiple pustules whiteheads with hair visible at the center and erythematous base usually on arms legs face and buttocks traumatic alopecia
repeated headaches that can occur for weeks to months at a time, followed by periods of remission; characterized by attacks of intense unilateral pain that occurs most often over the eye and forehead. migraine severe vascular headache preceded by auras that may include nausea and vomiting meningeal inflammation acute onset of stiffness with headache and fever shows this inflammation hyperthyroidism condition of hypersecretion of the thyroid gland characterized by exophthalmia, tachycardia, goiter, and tumor hypothyroidism condition of hyposecretion of the thyroid gland causing low thyroid levels in the blood that result in sluggishness, slow pulse, and often obesity CVA tenderness costovertebral angle; firmly tapping over the kidneys - + if it produces pain (suggests renal pain) Bell's palsy
temporary paralysis of the seventh cranial nerve that causes drooping only on the affected side of the face tympanostomy tube ..., ear tubes inserted to relieve middle ear pressure n allow drainage from repeated middle ear infection position of ear for adult up and back position of ear for child down and back teething the process of the teeth pushing their way through the gums ~6- 7 months epistaxis most common site for nosebleed is kiesselbach plexus in anterior septum may be spontaneous or a sign of underlying illness posterior hemorrhage is less common more profuse and harder to manage sinuitis
location size shape consistency movable distinctness nipple(displaced or retracted) note skin over lump tenderness lymphadenopathy beginning of breast development precedes menarche by years 2 apices of lung 3 - 4 cm above the clavicle base of lung lower border of lung; rests on the diaphragm at about the sixth rib in the midclavicular line (T 10 posteriorly) bronchophony normal= soft muffled indistinct
abnormal= more distinct Increase in intensity and clarity of the vocal resonance that may result from an increase in the lung tissue density, such as in the consolidation of PNEUMONIA egophony normal=eeeee abnormal=aaaaa a change in the voice sound of a patient with PLEURAL EFFUSION or PNEUMONIA as heard on auscultation. When the patient is asked to make /ē-ē-ē/ sounds, they are heard over the peripheral chest wall as /ä-ä-ä/, particularly over an area of consolidated or compressed lung above the effusion. significance of unequal chest expansion abnormal wide costal angel with little inspiratory variation occurs with atelectasis, pneumothroax, lobar pneumonia, pneumonia weeks primitive lung emerges weeks conducting airways reach same # as in adults weeks surfactant is present in adequate amounts ...5;16; aortic pulse pulse located at the right 2nd intercostal space
end of systole closing of semilunar( aortic and pulmonic valves) S abnormal heart sound Usual cause is myocardial failure. Occurs immediately after S2 (early diastole). Heard best at apex listen with bell. Low pitch. S an abnormal heart sound detected late in diastole as resistance is met to blood entering either ventricle during atrial contraction; most often caused by hypertrophy of the ventricle aortic stenosis allen test Determining the patency of the radial and ulnar arteries by compressing one artery site and observing return of skin color as evidence of patency of the other artery CVA tenderness Pain felt when gently tapping the area of the back overlying the kidney(~12 rib). Sign of inflammation, infection of the kidney eg pyleonephritis
black tarry stools significance? occult blood upper GI Right Upper Quadrant Liver Gallbladder Duodenum Head of pancreas Right kidney Hepatic flexure of colon Top of ascending and part of transverse colon Right Lower Quadrant Cecum Appendix Right ovary and tube Right ureter Right spermatic cord Left Upper Quadrant Stomach Spleen
tennis elbow Inflammation of the common tendon of origin for all posterior forearm muscles. Patient has pain around lateral epicondyle with radiation down lateral forearm. AKA: lateral epicondylitis phalens test Ask the person to hold both hands back to back while flexing the wrists 90 degrees. Acute flexion of the wrist for 60 seconds produces no symptoms in the normal hand. (produces numbness and burning in a person with carpal tunnel). tinels test tap the median nerve test for carpal tunnel allis test
- used to check hip dislocation by comparing leg lengths.
- place baby's feet flat on the table, and flex the knees up.
- knees should be at same elevation ortolani test Abduct thighs and apply gentle pressure forward over greater trochanter. Clunking sensation indicates femoral head moving into acetabulum. Hip click may be felt or heard but that is normal. (Butterfly stretch)
kinesthesia sense that allows the brain to be constantly aware of the position and movement of muscles in different parts of the body (without this, coordinated movements with your eyes closed would be impossible) extinction ... sterognosis ability to perceive the form of an object by using the sense of touch graphesthesia Ability to identify letters, numbers, or shapes drawn on the skin tactile discrimination Requires interpretation by the cerebral cortex. sterognosis, graphesthesia, 2 pt disc, point location cerebrum largest part of the brain; responsible for voluntary muscular activity, vision, speech, taste, hearing, thought, and memory
