2024-2025 NR 304 |NR 304 FINAL EXAM TEST BANK
ALL QUESTIONS AND CORRECT DETAILED
ANSWERS ALREADY A GRADED |NEW AND
REVISED
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 - CORRECT ANSWER- How do you count respirations?
Vasoconstriction of the arteries which makes your blood pressure
increase. Long-term cause of hypertension - CORRECT ANSWER-
What are the effects of smoking on blood pressure?
Asymmetry, border irregularity, color variation, diameter greater than
6mm, elevation/evolution, funny looking - CORRECT ANSWER- What
is the ABCDEF skin lesions mean?
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 -
CORRECT ANSWER- What are the physiological changes associated
with acute pain responses?
,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° -
CORRECT ANSWER- How do you assess for clubbing?
Smoking, lung cancer, pulmonary disease, congenital cyanotic heart
disease - CORRECT ANSWER- What patients does clubbing occur?
Generalized pallor - CORRECT ANSWER- How do you detect pallor in
a light skinned patient?
Ashen gray, dull, loss of glow, cool to palpation - CORRECT
ANSWER- How do you detect pallor in a dark skinned patient?
Yellow sclera, hard palate, skin, mucous membranes - CORRECT
ANSWER- How do you detect jaundice in a light-skinned patient?
Observe the palms, hard and soft palates - CORRECT ANSWER- How
do you observe jaundice in a dark skinned patient?
Dusky blue appearance - CORRECT ANSWER- How do you observe
cyanosis in a light skinned patient?
Dullness, check conjunctiva, oral cavity, nails - CORRECT ANSWER-
How do you observe cyanosis in a dark skinned patient?
,Red or bright pink color - CORRECT ANSWER- How do you observe
erythema in a light skin patient?
Purpleish tinge, difficult to observe, palpate for warmth - CORRECT
ANSWER- How do you observe erythema in a dark skinned patient?
Stage 1 non-blanchable erythema
Intact skin with a localized area of non-blanchable erythema -
CORRECT ANSWER- What is the name and characteristics of a stage
one pressure injury?
Stage 2 partial thickness skin loss
Partial skin loss with an exposed dermis. Pink/red and moist visible
wound base. Looks like a ruptured blister. Usually associated with
moisture. Slough and eschar not noted. - CORRECT ANSWER- What is
the name and characteristics of a stage 2 pressure injury?
Stage 3: Full-Thickness Skin Loss
For thickness loss of skin. Adipose is visible in ulcer and granulation
tissue with epibole. Slough and eschar may be noted. Tunneling and
undermining may occur. - CORRECT ANSWER- What is the name and
characteristics of a stage 3 pressure injury?
Stage 4: Full thickness skin/tissue loss
Full thickness skin and tissue loss with muscle/bone/tendon/ligament
exposed. Slough, Eschar, epibole, undermining, tunneling may be
, present. - CORRECT ANSWER- What's the name and characteristic of
a stage 4 pressure injury?
Touch chin to chest, turn head right and left, touch ear with shoulder
without elevating the shoulders, extend head backwards - CORRECT
ANSWER- How do you assess the range of motion of the neck?
Non-pitting Edema, fatigue, cold intolerance, puffy Edematous face,
Peri orbital Edema, puffy hands/feet, course facial/hair features, cool/dry
skin, slow reflexes, occasionally thick speech. - CORRECT ANSWER-
What are the manifestations of hypothyroidism?
Progress towards outcomes, use ongoing assessment to revise
diagnoses/outcomes/plans, disseminate results to patient and family -
CORRECT ANSWER- What happens during the evaluation step of the
nursing process?
Compare clinical findings with normal and abnormal variation and
developmental events, interpret data, validate and document diagnoses. -
CORRECT ANSWER- What happens during the diagnosis stage of the
nursing process?
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.
