Nurs 258 Final Exam Study Guide with Complete Solutions 2024/2025 Order of physical assessment skills - Correct Answer inspection, palpation, (percussion), auscultation Frequency of VS - Correct Answer MD orders, critical situations, after surgery, during blood transfusions, changes in pt status Factors that affect temperature - Correct Answer age, exercise, hormone changes, circadian rhythm, stress, environment, illness and injury Apical pulse location - Correct Answer 5th intercostal space, left mid-clavicular line Why might you take an apical pulse? - Correct Answer most accurate and when pt is on cardiac meds Factors the influence pulse - Correct Answer exercise, temperature, emotions, meds, hemorrhage, postural changes Factors affecting respirations - Correct Answer exercise, acute pain, anxiety, smoking, body position, medications, neurological injury, hemoglobin function Alterations in breathing pattern - Correct Answer bradypnea, tachypnea, hyperpnea, apnea, hyperventilation, hypoventilation Factors affecting BP - Correct Answer age, stress, ethnicity (AA men higher BP), meds, activity, weight, smoking How much change in BP would indicate orthostatic hypotension? - Correct Answer drop in 20 mmHg systolic How would you estimate systolic BP? - Correct Answer 1. palpate radial pulse
- inflate cuff until pulse disappears
- deflate cuff slowly
- record mmHg where pulse reappears 1 / 2
When should the nurse start checking BP on children? - Correct Answer not until at least 3 years old When assessing children specifically for mental status what area's should the nurse check? - Correct Answer head control, motor development, sensory development (7-9 months fully developed), Babinski reflex (children fan toes, adults flex feet and toes) LOC: alert - Correct Answer Awake or readily aroused, oriented, fully aware of external and internal stimuli and responds appropriately LOC: lethargic - Correct Answer not fully alert, drifts off to sleep easily, can be aroused to name but is drowsy, responses seem slow and fuzzy, spontaneous movements are decreased LOC: obtunded - Correct Answer transitional state between lethargy and stupor, difficult to arouse- needs loud shout or vigorous shakes, acts confused when is aroused, speech may be mumbled and incoherent LOC: stupor or semi-coma - Correct Answer responds only to vigorous shaking or pain with groans, may have appropriate motor response LOC: coma - Correct Answer completely unconscious, no response to pain or any external light coma = some reflex deep coma = no motor response LOC: delirium (Acute Confusional State) - Correct Answer clouding of consciousness, impaired alertness, inattentive, agitation, hallucinations, disoriented mood vs affect - Correct Answer mood is external expression of state of mind vs affect being more internal prolonged display of feelings Abstract reasoning - Correct Answer pondering a deeper meaning beyond the concrete and literal Abstract reasoning involves 3 components - Correct Answer though process, thought content, preceptions
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