NRSG 2220-Exam 1 (Mod 1-5)
Questions & Answers41
The nurse should use the bell of the stethoscope during auscultation of: - ANSWERS-a client's
heart murmur.
The bell of the stethoscope is used to listen to low-pitched sounds, such as heart murmurs. The
diaphragm of the stethoscope is used to listen to high-pitched sounds such as normal heart
sounds, breath sounds, and bowel sounds.
What is a chief concern? - ANSWERS-The first subject discussed in a client interview is the
client's specific reason for seeking care. The subject is often called the client's chief complaint or
chief concern.
BP Interpretation in adults - ANSWERS-Normal 100-120/60-80
Prehypertension 120-139/80-89
Hyper st 1 140-159/90-99
Hyper st 2 mod 160-179/100-109
Hyper st 2 sev 180-209/110-119
Hyper st 2 crisis >210/>120
What organs are at risk for permanent damange with high BP? - ANSWERS-Brain, Heart, and
kidneys
Nursing interventions for orthostatic hypotension - ANSWERS-Rise from lying to sitting slowly
and then sit on side of bed until they feel better
,Normal O2 Sat - ANSWERS->96% normal
<93% need for supplemental oxygen
O2 sensors can go on... - ANSWERS-finger, toe, ear, nose forehead
88% O2 sat - ANSWERS-requires home O2
Height and Weight ratio is a good indicator of... - ANSWERS-nutrition status
hydration status
general health
General Survey: - ANSWERS--Provides clues to overall health
-Begins the moment of contact
-First impressions
-Challenges your observational skills
-Usually includes vital signs, height and weight. We are focusing on skillful observations
What do you look for in skilled observation (general survey)? - ANSWERS--Signs of distress
-Stature/Build
-Dressing/Grooming
-Posture/Gait/Coordination
-Eye contact
-Level of consciousness, mood
- Speech patterns
-Vision or hearing problems
-Nutritional state
,-Significant others accompanying patient
Healthy hair=
(general survey) - ANSWERS-Healthy protein stores in body
Pain is a subjective or objective experience? - ANSWERS-Subjective
-highly individual
-ethnocultural considerations
Expression of pain does not = - ANSWERS-degree of pain
5th vital sign? - ANSWERS-Pain
How do you care for the patient in pain? - ANSWERS--Important to believe the pain is real
-Your goal is to reduce/eliminate pain and manage pain so that patient can resume normal
lifestyle
Best indicator of pain? - ANSWERS-Patient reporting their pain to you
Standards to treat/manage pain as put in place by the Joint Commission - ANSWERS-These
standards uphold the idea that the patient has the right to have their pain managed effectively.
One important standard is to determine a pain rating goal with your patient.
Their plan of care is set on mutually set goals
Characteristics of Pain - ANSWERS-COLD ERA
COLD ERA - ANSWERS-C:haracter of the compaint
, O:nset of the symptom
L:ocation of the complaint
D:uration of the problem
E:xacerbated by what?
R:elieved by what?
A:ssociated symptoms problem
OLD CARTS - ANSWERS-O:nset
L:ocation
D:uration
C:haracter
A:ggravating factors/associated factors
R:elieving factors
T:emporal factors
S:everity
Duration of pain (3) - ANSWERS-Acute
-rapid onset, varies with intensity, protective in nature
Chronic
-can be intermittent or persistent, long-standing pain and it interferes with ability to function
Acute on chronic
-someone who has chronic pain and then has acute exacerbation of pain on top of chronic pain
Remission of pain - ANSWERS-No symptoms of pain at the time
Questions & Answers41
The nurse should use the bell of the stethoscope during auscultation of: - ANSWERS-a client's
heart murmur.
The bell of the stethoscope is used to listen to low-pitched sounds, such as heart murmurs. The
diaphragm of the stethoscope is used to listen to high-pitched sounds such as normal heart
sounds, breath sounds, and bowel sounds.
What is a chief concern? - ANSWERS-The first subject discussed in a client interview is the
client's specific reason for seeking care. The subject is often called the client's chief complaint or
chief concern.
BP Interpretation in adults - ANSWERS-Normal 100-120/60-80
Prehypertension 120-139/80-89
Hyper st 1 140-159/90-99
Hyper st 2 mod 160-179/100-109
Hyper st 2 sev 180-209/110-119
Hyper st 2 crisis >210/>120
What organs are at risk for permanent damange with high BP? - ANSWERS-Brain, Heart, and
kidneys
Nursing interventions for orthostatic hypotension - ANSWERS-Rise from lying to sitting slowly
and then sit on side of bed until they feel better
,Normal O2 Sat - ANSWERS->96% normal
<93% need for supplemental oxygen
O2 sensors can go on... - ANSWERS-finger, toe, ear, nose forehead
88% O2 sat - ANSWERS-requires home O2
Height and Weight ratio is a good indicator of... - ANSWERS-nutrition status
hydration status
general health
General Survey: - ANSWERS--Provides clues to overall health
-Begins the moment of contact
-First impressions
-Challenges your observational skills
-Usually includes vital signs, height and weight. We are focusing on skillful observations
What do you look for in skilled observation (general survey)? - ANSWERS--Signs of distress
-Stature/Build
-Dressing/Grooming
-Posture/Gait/Coordination
-Eye contact
-Level of consciousness, mood
- Speech patterns
-Vision or hearing problems
-Nutritional state
,-Significant others accompanying patient
Healthy hair=
(general survey) - ANSWERS-Healthy protein stores in body
Pain is a subjective or objective experience? - ANSWERS-Subjective
-highly individual
-ethnocultural considerations
Expression of pain does not = - ANSWERS-degree of pain
5th vital sign? - ANSWERS-Pain
How do you care for the patient in pain? - ANSWERS--Important to believe the pain is real
-Your goal is to reduce/eliminate pain and manage pain so that patient can resume normal
lifestyle
Best indicator of pain? - ANSWERS-Patient reporting their pain to you
Standards to treat/manage pain as put in place by the Joint Commission - ANSWERS-These
standards uphold the idea that the patient has the right to have their pain managed effectively.
One important standard is to determine a pain rating goal with your patient.
Their plan of care is set on mutually set goals
Characteristics of Pain - ANSWERS-COLD ERA
COLD ERA - ANSWERS-C:haracter of the compaint
, O:nset of the symptom
L:ocation of the complaint
D:uration of the problem
E:xacerbated by what?
R:elieved by what?
A:ssociated symptoms problem
OLD CARTS - ANSWERS-O:nset
L:ocation
D:uration
C:haracter
A:ggravating factors/associated factors
R:elieving factors
T:emporal factors
S:everity
Duration of pain (3) - ANSWERS-Acute
-rapid onset, varies with intensity, protective in nature
Chronic
-can be intermittent or persistent, long-standing pain and it interferes with ability to function
Acute on chronic
-someone who has chronic pain and then has acute exacerbation of pain on top of chronic pain
Remission of pain - ANSWERS-No symptoms of pain at the time
