URI NURSING 203 FINAL EXAM Questions With Correct Answers

URI NURSING 203 FINAL EXAM Questions With
Correct Answers

First Level Priority - CORRECT ANSWER✔✔-ABCs plus V
| | | | | | |




Airway
Breathing
Circulation Problems |




Delirium |




Vital Sign Concerns
| |




Second Level Priority - CORRECT ANSWER✔✔-Mental status changes, acute pain,
| | | | | | | | | |


abnormal lab values, untreated medical problems
| | | | |




Third Level Priority - CORRECT ANSWER✔✔-anything else- rest, family coping
| | | | | | | | |




Maslow's Hierarchy - CORRECT ANSWER✔✔-High Priority: life-threatening- ABC,
| | | | | | | |


food, water, sex, sleep
| | |




Next level safety and security, love, belonging and self esteem
| | | | | | | | |




Phase 1: Pre-Interview - CORRECT ANSWER✔✔-Set stage
| | | | | |




Gather data |




identify own biases and assumptions
| | | |




check environment
|

,review own clinical behavior and appearance
| | | | |




Phase 2: introduction - CORRECT ANSWER✔✔-put client at ease, introduce
| | | | | | | | | |


yourself, explain purpose of assessment, approximate time for interview, brief
| | | | | | | | | |


social talk, tell client this is confidential
| | | | | |




Phase 3: working phase - CORRECT ANSWER✔✔-invite patients story, obtain data,
| | | | | | | | | |


identify and respond to emotional cues, expand and clarify patients story, ask
| | | | | | | | | | | | |


questions and obtain information, maintain eye contact, negotiate a plan
| | | | | | | | |




OLD CART - CORRECT ANSWER✔✔-Onset
| | | |




Location
Duration
Characteristics
Associated manifestations |




Relieving factors |




Treatment


Phase 4: termination - CORRECT ANSWER✔✔-summarize important points, ask if
| | | | | | | | | |


there is anything else the client would like to discuss, explain results of interview,
| | | | | | | | | | | | | |


explain how the PE will be conducted
| | | | | |




Systolic Blood Pressure - CORRECT ANSWER✔✔-blood is pushed into the arteries
| | | | | | | | | | |


and the arteries stretch. Greatest Pressure
| | | | |

, Diastolic Pressure - CORRECT ANSWER✔✔-Ventricles rest and arteries recoil,
| | | | | | | | |


resting phase of cardiac cycle. Lowest presure.
| | | | | |




BP Cuff Width - CORRECT ANSWER✔✔-40% of upper arm circumference
| | | | | | | | |




BP Cuff length - CORRECT ANSWER✔✔-80% of upper arm circumference
| | | | | | | | |




If cuff is TOO SMALL - CORRECT ANSWER✔✔-false high reading
| | | | | | | | |




`if cuff is TOO LARGE - CORRECT ANSWER✔✔-False LOW reading on small arm
| | | | | | | | | | | |




False HIGH reading on a large arm
| | | | | |




If brachial artery is BELOW heart - CORRECT ANSWER✔✔-BP will be HIGH
| | | | | | | | | | |




If brachial artery is ABOVE heart - CORRECT ANSWER✔✔-BP will be LOW
| | | | | | | | | | |




Where should the lower border of the cuff be on patient? - CORRECT
| | | | | | | | | | | | |


ANSWER✔✔-2.5 cm above the antecubital crease | | | | |




LOOSE cuff leads to... - CORRECT ANSWER✔✔-false HIGH readings
| | | | | | | |




Estimate systolic pressure by - CORRECT ANSWER✔✔-palpating brachial artery
| | | | | | | | |


while inflating cuff until you can't feel the pulse anymore and add 30 mm Hg to
| | | | | | | | | | | | | | | |


that number |