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NUR 336 Midterm Exam Blueprint
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NUR 336 Midterm Exam Blueprint
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NUR 336 Midterm Exam BlueprintAbduction → Correct Answers think of like a child abduction
(i know it's morbid lol) but you are taking something away from
where it normally is
Adduction → Correct Answers think of ADDing something to
the body
Assessment of allergies Correct Answers Check to see if
patient has a red band that states that they have an allergy
Make sure to ask your patients their allergies → this also should
include asking what reaction occurs in response to the allergy
(need to know what to look for)
If a patient has an allergy take the extra step to ensure that what
you are administering or doing does not contain the allergen
Assisting with ambulation Correct Answers Before moving the
client out of bed it is important to determine the level of
assistance each client requires
For patients who are ill or recovering from surgery provide a
simple assist
For people who need more use a device such as a cane
Patients who have been on bed rest for awhile vertigo and
orthostatic hypotension
Begin the process by having clients sit up in bed for a few
minutes, then dangle their legs at the side of bed, help them to a
standing position at the side of the bed, final step is ambulation
,Bathing older adult clients Correct Answers Bathing once to
twice a week is optimal → due to the fact that skin breakdown is
so common in the older population
Bag bath is often used for these patients
Contains a no-rinse surfactant, a humectant to trap moisture, and
an emollient
CN V- trigeminal nerve Correct Answers Covers most of the
face → if a patient has a problem with this nerve it usually
involves the forehead, cheek, or jaw (3 areas of the trigeminal
nerve)
Check sensation in all of these locations using a dull and soft
object (also check sensation of scalp)
CN VII- facial nerve Correct Answers Controls facial
movements and expression
Assess patient for symmetry → have them wrinkle the forehead,
close his eyes, smile, puck his lips, show his teeth, and puff his
cheeks
Both of the sides of the face should move the same way
When patient smiles observe the nasolabial folds for weakness
and flattening
Complete bed bath: Correct Answers for patients who are
completely dependent in bed
Use a commercial bag bath or cleansing pack in order to kill
gram-negative organisms
Deep tendon reflexes scale Correct Answers Response is
measured on a 0 to 5 scale
0 - absent reflex
, 1 - weak reflex
2 - normal response
3 - brisk response
4 - hyperreflexia with non-sustained clonus
Clonus → involuntary and rhythmic muscle movement caused
by a permanent lesion in descending motor neurons
5 - hyperreflexia with sustained clonus
Deep tendon reflexes should be Correct Answers +2 bilaterally
with negative Babinski
Babinski is when you run your finger across the bottom of the
foot and the toes flare up (this is an expected finding in babies
but not adults)
BABInski is a normal finding in BABIes
Dorsiflexion → Correct Answers taking your toes and pointing
them to sky
Examples of therapeutic baths Correct Answers Oatmeal,
cornstarch, or other products are often added to relieve skin
irritation
Sitz bath is prescribed for patients who had rectal or perineal
surgery in order to reduce pain
Need prescription from provider
Eye Assessment Correct Answers Inspect external eye
structures: eyebrows, eyelids, eyelashes bilaterally
Even distribution of eyebrows, eyelashes, no ptosis bilaterally
Ptosis = eye dropping
Inspect conjunctiva, sclera, cornea, iris bilaterally
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