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NUR 168 Exam 1 CH 27 Questions And Answers
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NUR 168 Exam 1 CH 27 Questions And Answers
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NUR 168 Exam 1 CH 27 Questions And Answers1st thing you do when entering a pt. room Correct Answers
Knock on the door, identify yourself, state what you plan to do.
Abnormal breath sounds Correct Answers abnormal sounds or
noises heard over the lungs and airways, commonly leading to a
diagnosis of a respiratory or cardiac condition; also called
adventitious breath sounds
Wheeze, rhonchi, crackles, stridor, friction rub
allergies and what to document in the pt. chart Correct Answers
what they are allergic to
how the symptoms presented during an allergic reaction
assessing an elderly patient Correct Answers Geriatric
assessment should include detailed medical history and physical
examination, with particular focus on problems specific to the
elderly such as vision, hearing, nutrition, fall prevention, urinary
incontinence, osteoporosis, and preventative health.
assessing melanoma on skin: use ABCDE Correct Answers A:
Asymmetry- if a line is drawn through a mole, the two halves
will not match.
B: Border- the borders of an early melanoma tend to be uneven.
The edges may be scalloped or notched.
C: Color- having a variety of colors is another warning signal. A
number of different shades of brown, tan, or black could appear.
A melanoma may also become red, white, or blue.
, D: Diameter- melanomas usually are larger in diameter that the
size of the eraser on your pencil (1-4 inch or 6 mm), but they
may sometimes be smaller when first detected.
E: Evolving- any change in size, shape, color, elevation, or
another trait, or any new symptom such as bleeding, itching, or
crusting- points to danger.
Auscultation Correct Answers listening to sounds within the
body (second)
Best way to stop spread of infection Correct Answers hand
washing
Bluish (cyanosis) Correct Answers -Exposed areas, particularly
the ears, lips, inside of the mouth, hands and feet, and nail beds
-Cold environment, cardiac or respiratory disease (decreased
oxygenation)
breast exam Correct Answers yearly for women older than 40
men are at risk
Assessment primarily conducted to identify any lumps in the
breasts and/or enlargement or pain in axillary lymph nodes.
Changes to look for include: lumps, change in size or shape,
skin irritation, pain, redness or discharge of the nipple, and
swelling.
cardiac landmarks Correct Answers 1. AORTIC - just right of
the sternum at the second ICS
2. PULMONIC - just left of the sternum at the second ICS
3. ERB'S POINT - just left of the sternum at the third ICS
4. TRICUSPID - just left of the sternum at the fourth ICS
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