nr304 final exam study guide nr 304 final exam review latest 2021 chamberlain college of nursing
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Chamberlain College Of Nursing
NR304
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Pulse- palpate or auscultate an apical rate
Respirations- watch infants abdomen for diaphragmatic respirations; sleeping rate
most accurate
a. Neonate = 30-40 bpm
b. 1 y/o = 20-40 bpm
c. 2 y/o = 25-32 bpm
Blood Pressure- annual BP 3 y/o and up; most common error is wrong size cuff;
crying stopped for 5-10 mins before measuring
- Peripheral Artery Disease
Affects noncoronary arteries supplying the limbs; usually caused by
atherosclerosis
More men have PAD than women
S/s- coolness in skin, weak thready pulse
Ankle-Brachial Index of 0.9 or lower = PAD
Beginning vs end stage?
- COPD
Obstruction of air flow
S/s- barrel chest, wheezing, decreased breath sounds, accessory muscle use,
clubbing, paradoxical pulse
A-P diameter = transverse
- Contact Dermatitis
Local inflammatory reaction to an irritant in the environment or an allergy
S/s- erythema, swelling, wheals (urticaria), maculopapular vesicles, scales,
intense pruritus
Can be caused by poison ivy
Vaginal-
a. Red, swollen vesicles
b. Weeping of lesions
c. Crusts
d. Scales
e. Thickening of skin
, 3
f. Excoriations from scratching
g. Pruritus
Diaper Dermatitis-
a. Red, moist, maculopapular patch with poorly defined borders in the diaper
area,
b. Extending along inguinal and gluteal folds
c. History of infrequent diaper changes or occlusive coverings
d. Inflammatory disease caused by skin irritation from ammonia, heat,
moisture, occlusive diapers.
Atopic Dermatitis (Eczema)-
a. Erythematous papules and vesicles, with weeping, oozing, and crust
b. Lesions usually on scalp, forehead, cheeks, forearms, and wrist, elbows,
back of knees
c. Paroxysmal and severe pruritis
d. Family history of allergies
- Pursed Lip Breathing
Inhaling through the nose and exhaling through pursed lips
Lips are puckered when exhaling
Helps the airways stay open during exhalation
- Emphysema
Caused by destruction of pulmonary connective tissue; permanent enlargement of
the air sacs distal to terminal bronchioles and rupture of interalveolar walls;
increased airways resistance; hyperinflated lung and increased lung volume
S/s-
a. Increased AP diameter (barrel chest)
b. Accessory muscle use
c. Tripod position
d. SOB
e. Respiratory distress
f. Tachypnea
g. Decreased tactile fremitus
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