Assessment, Nutrition

Question 1

usually 1° F (0.5° C) higher than the normal oral temperature

Answer 1

Rectal temperature

Question 2

about 1° F (0.5° C) lower than the normal oral temperature

Answer 2

tympanic and axillary temperature

Question 3

oral temp contraindicated when:

Answer 3

wait 15-30mins after cold or hot drink

-nasal congestion
-nasal or oral surgery or had the jaws wired
-NGT
-unable to keep the mouth closed
-seizure prec

Question 4

rectal temp contraindicated when:

Answer 4

place pt in Sim’s position

-cardiac pt
-rectal surgery
-diarrhea
-fecal impaction
-rectal bleeding or risk for bleeding

Question 5

tympanic temp contraindicated when:

Answer 5

-inflammation auditory canal
-discharge from the ear

❌reading may be affected by an ear infection or excessive wax blocking the ear canal.

Question 6

least accurate of all temp area

Answer 6

axillary temp

Question 7

if pedal pulse is difficult to locate

Answer 7

use doppler utx stethoscope/
ultrasonic stethoscope

Question 8

one-examiner technique in pulse deficit

Answer 8

Auscultate and count the apical pulse first and then immediately count the radial pulse

Question 9

two-examiner technique in pulse deficit

Answer 9

One person counts the apical pulse and the other counts the radial pulse simultaneously.

Question 10

pulse pressure

Answer 10

difference between the systolic and diastolic pressures

Question 11

orthostatic v/s

Answer 11

check BP and pulse supine, sitting, and standing;
readings are obtained 1 to 3 minutes after changing of position.

Question 12

arm BP cuff contraindicated when

Answer 12

wait for 30mins after smoke/exercise

-extremity w/ IV fluids
-AV shunt or fistula
-the side on which breast or axillary surgery has been performed, -extremity that has been traumatized or is diseased.

Question 13

cutaneous stimulation for pain

Answer 13

hot, cold, pressure, vibration, therapeutic touch, massage

Question 14

application of a battery-operated device that delivers a low electrical current to the skin and underlying tissues to block pain (some similar units can be purchased without a prescription)

Answer 14

TENS/PENS
(trans-/percutaneous electrical nerve stimulation)

Question 15

blood samples will be inaccurate if:

Answer 15

-drawn blood from an extremity w/ IV
-prolonged use of torniquet (⬆️K)

Question 16

aPTT is to _____, PT is to _____

Answer 16

heparin, warfarin

Question 17

can increase absorption of Vit. K

Answer 17

green leafy vegetables
*shortens PT result

Question 18

instrxn before
A. lipid panel
B. FBS

Answer 18

A.
-12-14 hrs fasting except water
-❌ alcohol 24hrs
-no eating high cholesterol the evening before
B.
-8-12 hrs fasting

Question 19

WBC shift to the right

Answer 19

too many mature/old neutrophils

Question 20

WBC shift to the left

Answer 20

too many immature neutrophils

Question 21

dairy products and fruit juices w/ pulps

Answer 21

not clear liquids

Question 22

hard candy, gelatin, ice pops, coffee&tea, lemonade, carbonated beverages,

Answer 22

clear liquid diet aside from water, bouillon, clear broth

Question 23

plain ice cream, sherbet, breakfast drinks, milk, pudding and custard, soups that are strained, refined cooked cereals, fruit juices, and strained vegetable juice

Answer 23

full liquid diet

Question 24

part of a clear and full liquid diet, with the addition of all cream soups, ground or diced meats, flaked fish, cottage cheese, rice, potatoes, pancakes, light breads, cooked vegetables, canned or cooked fruits, bananas, peanut butter, and nonfried eggs

Answer 24

mechanical soft diet

Question 25

foods to be avoided include nuts; dried fruits; raw fruits and vegetables; fried foods; tough, smoked, or salted meats; and foods with coarse textures

Answer 25

mechanical soft diet and soft diet

Question 26

easily digestible foods such as pastas, casseroles, tender meats, canned fruit, cooked vegetables, cakes, and cookies without nuts or coconut

Answer 26

soft diet

Question 27

All foods and seasonings are permitted; however, liquid, chopped, or pureed foods or regular foods with a soft consistency are tolerated best

Answer 27

soft diet

Question 28

Drinking fluids through a straw may be easier than drinking from a cup or glass; a straw may not be allowed for clients with dysphagia

Answer 28

soft diet

Question 29

white bread, refined cooked cereals, cooked potatoes without skins, white rice, and refined pasta

Answer 29

low fiber (low residue) diet

Question 30

limit or avoid raw fruits (except bananas), vegetables, nuts and seeds, plant fiber, and whole grains Dairy products should be limited to 2 servings a day

Answer 30

low fiber (low residue) diet

Question 31

fruits, vegetables, whole grains, low-fat dairy foods, meat, fish, poultry, nuts, and beans; it is limited in sugar-sweetened foods and beverages, red meat, and added fats.

Answer 31

DASH diet (Dietary Approaches to Stop Hypertension)

Question 32

fruits and vegetables and whole-grain products

Answer 32

high fiber (high residue) diet

Question 33

for malabsorption disorders, pancreatitis, gallbladder disease, and gastroesophageal reflux Used to reduce symptoms of abdominal pain, steatorrhea, flatulence, and diarrhea associated with high intakes of dietary fat

Answer 33

fat restricted diet

Question 34

for severe stress, burns, wound healing, cancer, human immunodeficiency virus, acquired immunodeficiency syndrome, chronic obstructive pulmonary disease, respiratory failure, or any other type of debilitating disease

Answer 34

high calorie high protein diet

Question 35

whole milk and milk products, peanut butter, nuts and seeds, beef, chicken, fish, pork, and eggs

Answer 35

high calorie high protein diet

Question 36

snack between meals (milkshakes, instant breakfasts, nutri supplements)

Answer 36

high calorie high protein diet

Question 37

for diabetes mellitus, hypoglycemia, hyperglycemia, and obesity

Answer 37

carbohydrate consistent diet

Question 38

Exchange System for Meal Planning

Answer 38

carbohydrate consistent diet

Question 39

for hypertension, heart failure, renal disease, cardiac disease, and liver disease

Answer 39

sodium restricted diet

Question 40

4 g daily (no-added-salt diet), 2 to 3 g daily (moderate restriction) 1 g daily (strict restriction) 500 mg daily (severe restriction and seldom prescribed)

Answer 40

sodium restricted diet

Question 41

for renal disease and end-stage liver disease

Answer 41

protein restricted diet

Question 42

for celiac disease and gluten sensitivity

Answer 42

gluten free diet

Question 43

for the client with acute kidney injury or chronic kidney disease and those requiring hemodialysis or peritoneal dialysis

Answer 43

renal diet

Question 44

fluid restrictions on dialysis pt

Answer 44

hemodialysis pt have more fluid restrictions than peritoneal dialysis pt

Question 45

applesauce, green beans, cabbage, lettuce, peppers, grapes, blueberries, cooked summer squash, cooked turnip greens, pineapple, and raspberries

Answer 45

low in potassium

Question 46

Avocado Bananas Cantaloupe Carrots Fish Mushrooms Oranges Pork, beef, veal Potatoes Raisins Spinach Strawberries Tomatoes

Answer 46

high in potassium

Question 47

for gout, kidney stones, and elevated uric acid

Answer 47

low purine diet

Question 48

anchovies, herring, mackerel, sardines, scallops, organ meats, gravies, meat extracts, wild game, goose, and sweetbreads

Answer 48

foods high in purine

Question 49

for clients with anemia

Answer 49

high iron diet

Question 50

organ meats, meat, egg yolks, whole-wheat products, dark green leafy vegetables, dried fruit, and legumes

Answer 50

foods high in iron

Question 51

aids in Iron absorption

Answer 51

Vitamin C

Question 52

Lacto-vegetarian

Answer 52

-avoid fish, meat, poultry, eggs - ➕milk, cheese, dairy products

Question 53

Vegan

Answer 53

-no animal foods -only foods with plant origin -use of soy

Question 54

Lacto-ovo-vegetarian

Answer 54

-same w/ lacto-vegetarian BUT ✅ egg (ovo=egg)

Question 55

ovo-vegetarian

Answer 55

-only egg -no dairy

Question 56

water soluble vitamins

Answer 56

vit b and c

Question 57

vit b complex

Answer 57

B1 thiamin B2 riboflavin B3 niacin B6 pyridoxine B9 folic acid B12 cyanocobalamin

Question 58

fat soluble vitamins

Answer 58

ADEK

Question 59

percussion

Answer 59

resonance- healthy lung hyperresonance-excessive air in lungs dullness- +lung densities, heart, liver, spleen tympany- abdomen flatness

Question 60

dark skinned patient

Answer 60

cyanosis: 1. gray color lips & tongue 2. blue color nailbeds, palms & soles 3. conjunctiva for pallor jaundice: yellow color in oral mucuos membranes & sclera bleeding: swelled/darker area & compare w/ unaffected side inflammation: warm, shiny, taut or pitting skin & compare w/ unaffected side

Question 61

crepitous/crepitation

Answer 61

crackling

Question 62

abdominal assessment

Answer 62

auscultation first before palpation & percussion

Question 63

romberg's test

Answer 63

stand, hands to the side, close eyes, pt should be able to balance

Question 64

Stereognosis

Answer 64

Tests the client’s ability to recognize objects placed in his or her hand

Question 65

Graphesthesia

Answer 65

Tests the client’s ability to identify a number traced on the client’s hand

Question 66

positive Brudzinski’s sign

Answer 66

➕ meningeal irritation passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column

Question 67

positive Kernig’s sign

Answer 67

➕ meningeal irritation knee and hip flexed then knee extended results to pain on the vertebral column

Question 68

dix hallpike maneuver

Answer 68

check for nystagmus

Question 69

sonorous wheeze

Answer 69

ronchi

Question 70

pleural friction rub

Answer 70

pleurisy leathery, scratchy sound

Question 71

bronchophony

Answer 71

ninety nine

Question 72

egophony

Answer 72

repeat eee-eee-eee sound

Question 73

whispered pectoriloquy

Answer 73

whisper one, two, three

Question 74

lordosis

Answer 74

swayback (curvature above buttocks)

Question 75

kyphosis

Answer 75

hunchback (curvature thorax area)

Question 76

scoliosis

Answer 76

lateral curvature

Question 77

stridor

Answer 77

upper airway obstrxn life threatening

Question 78

wheeze

Answer 78

asthma

Question 79

testicular self exam

Answer 79

after bath/shower (scrotum still warm, wet & soapy) perform same day each month

Question 80

cheyne stokes respiration

Answer 80

regular rate w/ apnea episodes

Question 81

murmur

Answer 81

loud blow of swoosh

Question 82

pericardial friction rub

Answer 82

leathery, scratchy sound

Question 83

conductive hearing loss

Answer 83

physical obstrxn

Question 84

sensorineural hearing loss

Answer 84

defective cochlea, cranial nerve 8 or brain

Question 85

vit b12 source

Answer 85

nuts, dried beans, organ meats, citrus fruits, green leafy, yeasts