Exam 2

Question 1

Review of Systems (ROS)

Answer 1

Systematic method for collecting data on all body systems

Question 2

Assessment Techniques

Answer 2

Inspection
Palpation
Percussion
Auscultation
Olfaction

Question 3

Back of hand

Answer 3

sensitive to temperature variations

Question 4

Pads of finger

Answer 4

subtle changes in texture, shape, size, consistency, and pulsation

Question 5

Palm of hand

Answer 5

vibration

Question 6

Auscultation

Answer 6

Listening to sounds produced by the body with a stethoscope

diaphragm for high pitch sounds

Question 7

Skin color variations with Anemia

Answer 7

Loss of pigmentation

Patchy area on skin over face, hands, arms

Question 8

yellow-orange skin color

Answer 8

Sclera, mucous membranes, skin
Increased deposit of bilirubin in tissues
indicates liver disease, destruction of red blood cells

Question 9

Red skin color

Answer 9

Face, area of trauma, sacrum, shoulders
Increased visibility of oxyhemoglobin caused by dilation or increased blood flow
Fever, trauma, blushing, alcohol intake

Question 10

Macule

Answer 10

Flat, nonpalpable change in skin color, smaller than 1 cm

Question 11

Papule

Answer 11

Palpable, circumscribed, solid elevation in skin, smaller than 0.5 cm

Question 12

Nodule

Answer 12

Elevated solid mass, deeper and firmer than papule, 0.5-0.2 cm

Question 13

Tumor

Answer 13

Solid mass that may extend deep through subcutaneous tissue, larger than 1-2 cm

Question 14

Wheal

Answer 14

Irregularly shaped, elevated area or superficial localized edema, varies in size

Question 15

Vesicle

Answer 15

Circumscribed elevation of skin, filled with serous fluid, smaller than 0.5 cm

Question 16

Varicella (shingles)

Answer 16

Seen in elderly, immune-compromised
Avoid contact if not had chicken pox
Painful

Question 17

Pustule

Answer 17

Circumscribed elevation of skin similar to vesicle but filled with pus, varies in size

Question 18

Ulcer

Answer 18

Deep loss of skin surface that may extend to dermis and frequently bleeds and scars, varies in size

Question 19

Atrophy

Answer 19

Thinning of skin with loss of normal skin furrow, with skin appearing shiny and translucent, varies in size

Question 20

Neurological assessment

Answer 20

Often is assessed as you perform your physical exam
Does patient follow simple and complex commands
Movement: assess as you perform hygiene, help ambulate, assist to toilet

Question 21

Thought Process

Answer 21

This is a description of the way in which they think

Question 22

Thought Content

Answer 22

A description of what the patient is thinking about

Question 23

1+ edema

Answer 23

Mild pitting, slight indentation, no perceptible swelling of the leg

Question 24

2+ edema

Answer 24

Moderate pitting, indentation subsides rapidly

Question 25

3+ edema

Answer 25

Deep pitting, indentation remains for a short time, leg looks swollen

Question 26

4+ edema

Answer 26

Very deep pitting, indentation lasts a long time, leg is very swollen

Question 27

S1

Answer 27

Closure of mitral & tricuspid valves Signals the beginning of systole Loudest at apex

Question 28

S2

Answer 28

Closure of aortic & pulmonic valves | Loudest at the base

Question 29

Jugular Venous Pressure

Answer 29

Reflect filling pressures & volume changes in right side of heart Evaluate with patient at 45-degree angle

Question 30

Pulse rating

Answer 30

``` 0 - Absent 1+ - Palpable but weak 2+ - Normal 3+ - Increased 4+ - Bounding D = Doppler ```

Question 31

Nursing process

Answer 31

``` Assessment Nursing diagnosis planning implementation evaluation ```

Question 32

Types of diagnoses

Answer 32

Actual Potential (Risk for) Wellness (Readiness for) Syndrome (6 in NANDA)

Question 33

Parts of the nursing diagnoses

Answer 33

``` Diagnostic Label (Problem) Related factors (Etiology) Defining characteristics (S+S) ```

Question 34

Ethnocentrism

Answer 34

superiority of a cultural, ethnic, or professional group

Question 35

Xenophobia

Answer 35

morbid fear of strangers

Question 36

Cultural Competence

Answer 36

set of cultural behaviors and attitudes integrated into the practice methods of a system, agency, or its professionals, that enables them to work effectively in cross cultural situations

Question 37

Direct communication

Answer 37

focuses on explicit meaning of words and dealing directly with conflict

Question 38

Indirect communication

Answer 38

not everything needs to be said, but can be implied

Question 39

Formal communication

Answer 39

emphasis on good manners, use of titles and honorifics and in general supports social hierarchical structures

Question 40

Informal communication

Answer 40

emphasizes being courteous in a casual manner, by use of first names on first acquaintances

Question 41

Cultural competence model (ASKED)

Answer 41

``` Awareness (personal biases) Skill Knowledge Encounters (how many encounters have you had) Desire ```