Theory/Lab NURS 341 - Final Exam
Questions With 100% Pass
what are the eye tests? (there are 3 of them)
- pupillary assessment
- extraocular muscle function (EOM):
6 cardinal fields of gaze
corneal light reflex
- visual acuity: snellen chart
what are the key compontents of eye assessments?
- gather subjective data (pain, history, etc)
- test visual acuity
- test visual fields
- inspect function
- inspect external eye structures
how can you as the nurse test the extraoccular muscle function (EOM)?
- 6 cardinal fields of gaze
- corneal light reflex (using a pen light)
how do you as the nurse test visual acuity?
the snellen chart
how does the snellen chart work?
if someone has 20/40 vision, that means you'd see the chart as clearly at 20 feet away
as someone with "normal" vision would see it from 40 feet away
as the nurse, what should you assess on the external ear of a patient?
,- size, shape of auricle, and position of alignment on head
- skin condition, any tenderness they may have
- evaluate external auditory medius (ear canal)
what are the subjective aspects of an ear assessment?
- pain
- infection
- infection history
- vertigo
as the nurse, what should you assess on the internal ear of a patient?
- tympanic membrane (color, characteristics, position and integrity)
what do large lymph nodes mean?
how do you complete a lymph node assessment on a patient/what is important to
remember?
- if larger than 1 cm they are considered large
- can indicate infection, allergy, neoplasm (possible cancer)
- baseline = should not be able to feel lymph nodes on a patient
- use both hands to compare both sides/lymph nodes on the neck
what does hyperthyroidism look like in a person? (what is their appearance like?)
- increased facial hair
- goiter (turkey/large neck)
- exophthalmos (bulging eyeballs)
HYPERthryoidism = HIGH signs and symptoms
**hyper = too much!!
what does hypothyroidism look like in a person? (what is their appearance like?)
- hair loss
- puffy face
HYPOthryoidism = LOW signs and symptoms
**hypo = too little/not enough!!
, what are the nursing considerations for dressing changes? (important things to
remember)
- make sure to check the patient for any allergies
- administer analgesic (pain) medications 30-60 minutes prior
- IV PRN pain medications can be given if they are ordered and you are on a time
crunch
- carefully position patient
- carefully remove tape
- gently clean wound edges
- manipulate dressing and drains to minimize stress on patient
list the aspects of a wound assessment:
- location of the wound (give anatomical landmarks)
- length of the wound (from head to toe)
- tissue type in wound bed (% of granulation, epithelial necrotic, slough)
- exudate (amount and type)
- tunneling or undermining
- skin color, tissue edema, and induration surrounding the wound
list the stages of pressure injuries:
stage I: non-blanchable erythema, intact skin
stage II: partial-thickness loss with exposed dermis
stage III: full-thickness skin loss; adipose (fat tissue) is visible
stage IV: full-thickness skin and tissue loss with exposed fascia, muscle, tendon,
ligament, cartilage or bone
what is a stage I pressure injury?
stage I: non-blanchable erythema, intact skin
what is a stage II pressure injury?
Questions With 100% Pass
what are the eye tests? (there are 3 of them)
- pupillary assessment
- extraocular muscle function (EOM):
6 cardinal fields of gaze
corneal light reflex
- visual acuity: snellen chart
what are the key compontents of eye assessments?
- gather subjective data (pain, history, etc)
- test visual acuity
- test visual fields
- inspect function
- inspect external eye structures
how can you as the nurse test the extraoccular muscle function (EOM)?
- 6 cardinal fields of gaze
- corneal light reflex (using a pen light)
how do you as the nurse test visual acuity?
the snellen chart
how does the snellen chart work?
if someone has 20/40 vision, that means you'd see the chart as clearly at 20 feet away
as someone with "normal" vision would see it from 40 feet away
as the nurse, what should you assess on the external ear of a patient?
,- size, shape of auricle, and position of alignment on head
- skin condition, any tenderness they may have
- evaluate external auditory medius (ear canal)
what are the subjective aspects of an ear assessment?
- pain
- infection
- infection history
- vertigo
as the nurse, what should you assess on the internal ear of a patient?
- tympanic membrane (color, characteristics, position and integrity)
what do large lymph nodes mean?
how do you complete a lymph node assessment on a patient/what is important to
remember?
- if larger than 1 cm they are considered large
- can indicate infection, allergy, neoplasm (possible cancer)
- baseline = should not be able to feel lymph nodes on a patient
- use both hands to compare both sides/lymph nodes on the neck
what does hyperthyroidism look like in a person? (what is their appearance like?)
- increased facial hair
- goiter (turkey/large neck)
- exophthalmos (bulging eyeballs)
HYPERthryoidism = HIGH signs and symptoms
**hyper = too much!!
what does hypothyroidism look like in a person? (what is their appearance like?)
- hair loss
- puffy face
HYPOthryoidism = LOW signs and symptoms
**hypo = too little/not enough!!
, what are the nursing considerations for dressing changes? (important things to
remember)
- make sure to check the patient for any allergies
- administer analgesic (pain) medications 30-60 minutes prior
- IV PRN pain medications can be given if they are ordered and you are on a time
crunch
- carefully position patient
- carefully remove tape
- gently clean wound edges
- manipulate dressing and drains to minimize stress on patient
list the aspects of a wound assessment:
- location of the wound (give anatomical landmarks)
- length of the wound (from head to toe)
- tissue type in wound bed (% of granulation, epithelial necrotic, slough)
- exudate (amount and type)
- tunneling or undermining
- skin color, tissue edema, and induration surrounding the wound
list the stages of pressure injuries:
stage I: non-blanchable erythema, intact skin
stage II: partial-thickness loss with exposed dermis
stage III: full-thickness skin loss; adipose (fat tissue) is visible
stage IV: full-thickness skin and tissue loss with exposed fascia, muscle, tendon,
ligament, cartilage or bone
what is a stage I pressure injury?
stage I: non-blanchable erythema, intact skin
what is a stage II pressure injury?
