NUR 235: FINAL EXAM with complete solutions.

NUR 235: FINAL EXAM with complete solutions.What is included in CBC labs (include normal findings)? Reb Blood Cell count (RBC): 4.2-5.8 Hemoglobin (Hgb): 14-17 Hematocrit (Hct): 42-52% White Blood Cell count (WBC): 4.5-11.1 Platelet count: 140-400 A patient's BUN is 60 mg/dL and serum creatinine is 3.0 mg/dL. these results suggest what? Abnormal; high findings 00:28 01:10 Describe COLD SPA. What is it used for? C - Character (Describe the sign or symptom: Is it sharp, burning, itchy? Etc) O - Onset (When did it begin?) L - Location (Where is it? Does it radiate?) (Point with one finger) D - Duration (How long does it last/Does it recur?) S - Severity (How bad is it? How much does it bother you?) [Use paint scale] P - Pattern (What makes it better or worse?) A - Associated factors (What other symptoms occur with it, and how does it affect you?) To further explore any further symptoms. What is the working phase of an interview? Facilitate a client's comments about their major biological data, the reasons or care, their history (including past and family), their lifestyle of health practices, developmental level of functional health pattern responses. Use critical thinking skills to listen for and observe cues, and to interpret and validate those data. Describe SBAR. S: Situation - State only what you have to communicate B: Background - Events that lead to the situation A: Assessment - State objective and subjective data that has to do with the situation R: Recommendation - What you believe needs to be done for the client Clinically, which is worse: Stupor or Obtunded? Stupor A 34 year old male's BP reads 140/90, what does this indicate? Stage I Hypertension During assessment of healthy adult, where would the nurse palpate the apical pulse? Fifth left intercostal space - mid clavicular line When should a nurse validate information? If there are any discrepancies between subjective and objective data How would a nurse validate information? Repeating assessment Clarify with additional questions Verify with another HCP How should a nurse document data? Clear, concise manner using appropriate terminology. Include subjective and objective data. Report only data and be as descriptive as possible. DO NOT write your interpretation of what the data means A nurse is reading the report from the night shift nurse and notices in room 21B that the patient is stupor. Upon entering the patients room, the nurse would expect what? Awakens only too vigorous and continuous stimulation (shaking or painful stimuli); moans; does not follow commands; withdraws from painful stimulus; returns to unresponsive sleep. They don't say real words, this person is very difficult to wake up What are the two reasons why a patient may experience a temperature above 99.9 degrees? Exposure and fever T/F: Hypocalcemia can lead to hypothermia True When is bradycardia a problem? When heart rate is too slow for a person's immediate physiological needs Who is bradycardia common for? Athletes A 7 year olds vital signs read: HR: 81 RR: 21 BP: 97/59 Would these be normal or abnormal? How do the differ from an adult? Normal In an adult, BP would be higher What is the difference between acute and chronic pain? Acute: Less than 6 months Chronic: More than 6 months This type of pain occurs in the abdominal cavity and causes chest pain. Visceral pain This type of pain starts at a specific source and expands throughout the body. Radiating pain This type of pain is often confused with neuropathic pain. Phantom pain What is the main difference between affective and cognitive dimensions? Affective: Emotions Cognitive: Beliefs/attitudes A patient's chart reads her BMI as 27. What does this mean? The patient is overweight T/F: Nutritional need increases for boys at ages 12-19. True T/F: Nutritional need increases for girls at ages 12-19. False, 10-15 y/o Calories should decrease by 20-25% at what age? 75 A patients skin appears grey and dull, the nurse would document this as ____. Pallor Full thickness skin loss with adipose visible is classified as what stage of pressure injury? Stage III T/F: Unstageable pressure injuries can be assessed by an RN. False because it is unclear how deep the tissue is damaged What does the ABCDE model stand for? Asymmetry Boarder Color Diameter Elevation What are the four ways to check temperature? Temporal Tympanic Oral Axillary When is our body's temperature at its highest? In the afternoon