"don't worry everything will be okay" Correct Answers false
assurance or reassurance
"nurse knows best" Correct Answers using authority
"there is a lump in the breast" vs. "your breast" Correct
Answers distancing
"you don't smoke, do you" Correct Answers leading/biased
questioning
A 60 year-old man is having his skin assessed. The patient tells
the nurse he has been a heavy smoker for the last 40 years. He
has clubbing of the fingernails. What does this finding tell the
nurse?
1) The patient has chronic hypoxia.
2) The patient has melanoma.
3) The patient has COPD.
4) The patient has asthma. Correct Answers he has chronic
hypoxia
A patient has a normal pupillary light reflex. The nurse
recognizes this indicates that:
1) the eyes converge to focus on the light.
2) light is reflected at the same spot in both eyes.
3) the eye focuses the image in the center of the pupil.
4) constriction of both pupils occurs in response to bright light.
Correct Answers constriction of both pupils occurs in response
to bright light
,ABCDE Skin Assessment Correct Answers A: asymmetry
B: border
C: color
D: diameter
E: elevation and enlargement
abducens Correct Answers eye movement to the sides
abnormal nail conditions: beau lines Correct Answers
depression across nail that extends beyond nail bed
abnormal nail conditions: paronychia Correct Answers red,
swollen, tender inflammation of nail folds
acute-bacterial
chronic-fungal
abnormal nail conditions: splinter hemorrhages Correct
Answers red-brown linear streaks from damage to nail bed
capillaries
abnormal shape of nails Correct Answers clubbing-greater
than 160 degrees
Absorption of nutrients takes place primarily in the: Correct
Answers small intestine
All except the following can trigger delirium in a hospitalized
patient age 65 or older:
1) Urinary tract infection
2) Recent loss
,3) Renal failure
4) Cellulitis Correct Answers recent loss
alopecia vs. hirsutism Correct Answers alopecia-loss of hair
hirsutism-excessive hair
Aphasia vs. Dysarthria Correct Answers aphasia-impaired
speech/writing-can't talk
dysarthria-weakness of muscle for speech, distorted speech
apnea=
bradypnea=
tachypnea=
orthopnea=
dyspnea= Correct Answers -lack of breathing
-slow breathing <10
-fast breathing >24 (shallow)
-ability to breathe easily only in upright pos
-difficult, labored breathing
Asking relevant questions Correct Answers provides further
exploration into a subject matter
assessment of older adult Correct Answers same format for
younger adult and add questions related to functioning, chronic
probs
auditory Correct Answers hearing
babinksi is Correct Answers abnormal in adults
, babinski reflex Correct Answers stroke the heel to see
reactions of the toes which flex/fan out; normal in infants, if
persists can indicate neurological problems
barriers to therapeutic communication Correct Answers -
providing false assurance
-giving unwanted advice
-using authority
-using avoidance language
-engaging in distancing
-professional jargon
-talking too much
-interrupting
-using "why" questions
bouchards nodes Correct Answers hard bony outgrowths in
middle joints
Brudzinski's sign Correct Answers Severe neck stiffness
causes a patient's hips and knees to flex when the neck is flexed.
Candidiasis Correct Answers yeast infection
capillary refill-normal of nails Correct Answers normal-color
return in less than 3 sec
cerebellar ataxia gait Correct Answers Staggering, wide-based
gait; difficulty with turns; uncoordinated movement with
positive Romberg sign.
Possible causes: Alcohol or barbituate effect on the cerebellum;
cerebellar tumor; multiple sclerosis