Nur 211 Final Exam
1. Explain the correct way to palpate the breast. p. 359-361: Pt supine with arm
over head -
There are several different techniques to assess for lumps. It is important that the
nurse has a systematic search pattern to thoroughly assess each breast, the tail of
Spence, and axillary lymph nodes.
2. Circular pattern for palpation: starts by palpating the areola first and moving
in a circular motion from the areola to the outer perimeter of the breast
3. Radial spoke pattern for palpation: also known as the wedge pattern, divides
the breast into wedges; starts at the periphery of the breast and palpates toward
the nipple
4. Vertical strip pattern for palpation: starts at the sternum palpating up and
down in straight lines toward the outer perimeter of the breast, ending up in the
axillary area
5. Describe the correct positioning for conducting a pap smear. p.363-364:
Ask the patient to undress from the waist down, but tell her that she may leave
her socks on; provide a gown, draping, and privacy for the patient.
Tell the patient that she can sit at the end of the examination table until the
healthcare provider is ready to perform the assessment; the healthcare provider will
assist the patient into the lithotomy position.
When the healthcare provider is ready to begin, assist the patient into the lithotomy
position by having the patient move her buttocks down to the end of the examination
table; ask the patient to place the heels of her feet into the stirrups; assist the patient
as needed for comfort and safety. Provide a sheet over her legs and knees for
privacy until the assessment begins.
6. Explain the needed patient teaching to treat and prevent constipation: Eat
a High fiber Diet, Eat fruits, veg and whole grains Avoid high fat foods like meat,
eggs and cheese (dairy)
Stay hydrated but avoid caffeine and alcohol (these will dehydrate you) keep
moving around and exercise
If needed- stool softener or laxatives
Do not read or be on phone while on toilet
7. Discuss the causes of projectile vomiting in adults. p.247: Projectile
vomiting without nausea is a sign of central stimulation of the medulla; could be
a sign of brain pathology or head trauma.
8. Identify the 3 organs located at the midline. p.251: Aorta Uterus
Bladder
, Nur 211 Final Exam
9. Describe how the jugular vein changes with congestive heart failure.
p.272: Visible distention is a sign of venous pressure elevation, commonly seen
in congestive heart failure and fluid overload.
10. Identify where the brachial, carotid, femoral and tibial pulses are located
and palpated.: Brachial Pulse : Medial side of arm at the antecubital fossa
space. Carotid Pulse: between the trachea and sternocleidomastoid muscle.
Femoral Pulse:along the crease midway between the pubic bone and the anterior
iliac crest.
Tibial Pulse: behind and below the medial malleolus.
11. Explain the rationale for the elderly's noncompliance with prescribed
medicines.: Most cases (75%) of nonadherence among older adults are
intentional due to cost or side effects of drugs
12. Identify the sound of percussion of the abdomen when there is air, fluid,
or a hematoma present.: Air-hollow, fluid - thudding sound, hematoma - (there
would be visual representation)
13. Explain all the steps for starting any physical assessment on a patient.
(Accept the abdomen): inspection, palpation, percussion, auscultation
14. Explain the necessary teaching for male patients with a family history of
breast cancer.: most common presentation of male breast cancer is painless,
palpable, subareolar lump or mass. may also present as erythema of skin,
scaling of the nipple, or nipple discharge
15. List the health screenings recommended for male patients and their
frequency.: testicular exam by doctor annually and self exams routinely
prostate screenings annually for men over age 50 or high risk men age 40+ male
breast exam - self exam . for men with fam hx of breast cancer semiannual
clinical exam (starting at age 35) baseline mamogram at age 40
16. Identify the elements of good patient care documentation.: documentation
should be clear, concise, and detailed. subjective data should be documented
using the patients exact words and quotation marks
17. Identify the purpose of health assessment for nurses.: Health assessment
is an essential skill to nursing practice. Assessing patients and being able to
identify normal from abnormal findings is an essential role of the RN. Nurses
must be able to use learned skills to collect information about patients' health
and physical well-being.
Health assessment means assessing the whole patient. This includes:
A method to establish a baseline health history by collecting pertinent patient health
status data
, Nur 211 Final Exam
An organized, systematic, ongoing process of collecting, validating, and clustering
data
Collecting different types of data about the individual's past and present health
Assessing factors influencing health and well-being, including physical
health
behavioral aspects of health
spirituality
social factors
economic-political aspects of health
cultural variations lifespan and
developmental considerations Performing
a physical examination.
18. Define the following integumentary conditions found in the elderly:
bulbus hematoma, subcutaneous abrasions, senile purpura, and epithelial
contusions.: bulbus hematoma - bulging subcutaneous abrasions - first few layers
are rubbed away (stage 2 ulcer) senile purpura - areas of ruptured fagile cappillaries
and brusing of of the skin,
caused by loss of subcutaneous fat (bruise or echhymosis area) epithelial
contusions - Think goose egg
19. Explain how best practices of health assessment are validated.: Nurses
need to maintain currency in their profession. Best practice assessments and
instruments have been validated by research. Nursing research and evidence-
based practice guide our assessments and clinical decisions to provide safe and
effective care.
Comorbidities - dx current & past
Labs & diagnostic testing related to dx
Objective information - where, how much (2+pitting edema in left lower extremity)
20. Describe the elements of a past health history portion of a health
assessment.: The health history records subjective and essential data. Subjective
data are pieces of information reported by the patient. Purposes of the health history
include: Document a database of past and present health including a medical
history of medical problems, hospitalizations, and surgeries.
Document family history.
Identify psychosocial factors influencing health and well-being.
Identify self-care and health promotion practices.
Determine strengths and weaknesses of the patient.
1. Explain the correct way to palpate the breast. p. 359-361: Pt supine with arm
over head -
There are several different techniques to assess for lumps. It is important that the
nurse has a systematic search pattern to thoroughly assess each breast, the tail of
Spence, and axillary lymph nodes.
2. Circular pattern for palpation: starts by palpating the areola first and moving
in a circular motion from the areola to the outer perimeter of the breast
3. Radial spoke pattern for palpation: also known as the wedge pattern, divides
the breast into wedges; starts at the periphery of the breast and palpates toward
the nipple
4. Vertical strip pattern for palpation: starts at the sternum palpating up and
down in straight lines toward the outer perimeter of the breast, ending up in the
axillary area
5. Describe the correct positioning for conducting a pap smear. p.363-364:
Ask the patient to undress from the waist down, but tell her that she may leave
her socks on; provide a gown, draping, and privacy for the patient.
Tell the patient that she can sit at the end of the examination table until the
healthcare provider is ready to perform the assessment; the healthcare provider will
assist the patient into the lithotomy position.
When the healthcare provider is ready to begin, assist the patient into the lithotomy
position by having the patient move her buttocks down to the end of the examination
table; ask the patient to place the heels of her feet into the stirrups; assist the patient
as needed for comfort and safety. Provide a sheet over her legs and knees for
privacy until the assessment begins.
6. Explain the needed patient teaching to treat and prevent constipation: Eat
a High fiber Diet, Eat fruits, veg and whole grains Avoid high fat foods like meat,
eggs and cheese (dairy)
Stay hydrated but avoid caffeine and alcohol (these will dehydrate you) keep
moving around and exercise
If needed- stool softener or laxatives
Do not read or be on phone while on toilet
7. Discuss the causes of projectile vomiting in adults. p.247: Projectile
vomiting without nausea is a sign of central stimulation of the medulla; could be
a sign of brain pathology or head trauma.
8. Identify the 3 organs located at the midline. p.251: Aorta Uterus
Bladder
, Nur 211 Final Exam
9. Describe how the jugular vein changes with congestive heart failure.
p.272: Visible distention is a sign of venous pressure elevation, commonly seen
in congestive heart failure and fluid overload.
10. Identify where the brachial, carotid, femoral and tibial pulses are located
and palpated.: Brachial Pulse : Medial side of arm at the antecubital fossa
space. Carotid Pulse: between the trachea and sternocleidomastoid muscle.
Femoral Pulse:along the crease midway between the pubic bone and the anterior
iliac crest.
Tibial Pulse: behind and below the medial malleolus.
11. Explain the rationale for the elderly's noncompliance with prescribed
medicines.: Most cases (75%) of nonadherence among older adults are
intentional due to cost or side effects of drugs
12. Identify the sound of percussion of the abdomen when there is air, fluid,
or a hematoma present.: Air-hollow, fluid - thudding sound, hematoma - (there
would be visual representation)
13. Explain all the steps for starting any physical assessment on a patient.
(Accept the abdomen): inspection, palpation, percussion, auscultation
14. Explain the necessary teaching for male patients with a family history of
breast cancer.: most common presentation of male breast cancer is painless,
palpable, subareolar lump or mass. may also present as erythema of skin,
scaling of the nipple, or nipple discharge
15. List the health screenings recommended for male patients and their
frequency.: testicular exam by doctor annually and self exams routinely
prostate screenings annually for men over age 50 or high risk men age 40+ male
breast exam - self exam . for men with fam hx of breast cancer semiannual
clinical exam (starting at age 35) baseline mamogram at age 40
16. Identify the elements of good patient care documentation.: documentation
should be clear, concise, and detailed. subjective data should be documented
using the patients exact words and quotation marks
17. Identify the purpose of health assessment for nurses.: Health assessment
is an essential skill to nursing practice. Assessing patients and being able to
identify normal from abnormal findings is an essential role of the RN. Nurses
must be able to use learned skills to collect information about patients' health
and physical well-being.
Health assessment means assessing the whole patient. This includes:
A method to establish a baseline health history by collecting pertinent patient health
status data
, Nur 211 Final Exam
An organized, systematic, ongoing process of collecting, validating, and clustering
data
Collecting different types of data about the individual's past and present health
Assessing factors influencing health and well-being, including physical
health
behavioral aspects of health
spirituality
social factors
economic-political aspects of health
cultural variations lifespan and
developmental considerations Performing
a physical examination.
18. Define the following integumentary conditions found in the elderly:
bulbus hematoma, subcutaneous abrasions, senile purpura, and epithelial
contusions.: bulbus hematoma - bulging subcutaneous abrasions - first few layers
are rubbed away (stage 2 ulcer) senile purpura - areas of ruptured fagile cappillaries
and brusing of of the skin,
caused by loss of subcutaneous fat (bruise or echhymosis area) epithelial
contusions - Think goose egg
19. Explain how best practices of health assessment are validated.: Nurses
need to maintain currency in their profession. Best practice assessments and
instruments have been validated by research. Nursing research and evidence-
based practice guide our assessments and clinical decisions to provide safe and
effective care.
Comorbidities - dx current & past
Labs & diagnostic testing related to dx
Objective information - where, how much (2+pitting edema in left lower extremity)
20. Describe the elements of a past health history portion of a health
assessment.: The health history records subjective and essential data. Subjective
data are pieces of information reported by the patient. Purposes of the health history
include: Document a database of past and present health including a medical
history of medical problems, hospitalizations, and surgeries.
Document family history.
Identify psychosocial factors influencing health and well-being.
Identify self-care and health promotion practices.
Determine strengths and weaknesses of the patient.
