Final

Question 1

Complete Database

Answer 1

comprehensive understanding of the patient’s health history and current state. It includes a complete health history and full physical examination

Question 2

Episodic Database

Answer 2

This database focuses on a specific health issue or problem. It is used to document the care provided for a particular episode of illness, such as an infection or injury

Question 3

Emergency Database

Answer 3

This database is used when rapid data collection is needed, often in critical situations where lifesaving measures are being taken. It focuses on the immediate needs and vital signs of the patient

Question 4

Follow-up Database

Answer 4

track the progress of a patient’s health condition, such as chronic illnesses or after a surgical procedure. It includes ongoing assessments and evaluations to monitor the patient’s status and adjust care accordingly.

Question 5

orthostatic hypotension

Answer 5

systolic pressure decreases by more than 20 mmHg or
diastolic pressure decreases by more than 10 mmHg with position
change from a lying or sitting position.

Question 6

primary lesions

Answer 6

arise directly from the skin and are not modified by external factors: pustules, bullae, papules, macules, nodules, vesicles, plaques

Question 7

secondary lesions

Answer 7

develop from the evolution of primary lesions, or as a result of external factors like scratching, trauma, or the healing process: scales, crusts, erosions, ulcers, fissures, atrophy, scar

Question 8

papule

Answer 8

elevated, firm,
circumscribed
areas that are less
than 1 cm in
diameter (warts and raised moles)

Question 9

erosion

Answer 9

Loss of part of the
epidermis
Depressed
Moist, glistening
Follows rupture of
vesicle or bulla (scratching at chickenpox)

Question 10

scales

Answer 10

Heaped up
Keratinized cells
Flaky skin
Irregular shape
Thick or thin
Dry or oily
Size varies (Seborrheic
dermatitis.)

Question 11

crust

Answer 11

Dried serum
Blood/purulent exudate
Slightly elevated
Size varies
Color—brown, red,
black, tan, or straw-
colored (eczema)

Question 12

clubbing

Answer 12

angle between nailbed and fold is 180 degrees or larger

Question 13

lymphatic system function

Answer 13

 conserve fluid and plasma proteins that leak out of capillaries
 form a major part of immune system that defends body against disease
 absorb lipids from intestinal tract

Question 14

cancerous lymph nodes

Answer 14

Enlarged, hard, painless nodes that are fixed to
underlying tissue, Lymphadenopathy of the supraclavicular nodes

Question 15

What structures does the nurse expect to see when inspecting inside the nares?

Answer 15

turbinates: Superior turbinate may not be in view - Middle and inferior turbinates appear light red color like nasal mucosa

Question 16

xerostomia causes

Answer 16

dehydration, certain medications, and underlying medical conditions. Other potential causes include radiation therapy, smoking, and some autoimmune diseases

Question 17

how to calculate pack years with tobacco smoking

Answer 17

multiply the number of packs of cigarettes smoked per day by the number of years smoked

Question 18

s/s that are identified on a lung exam in the presence of consolidation

Answer 18

• dull percussion of anterior chest
• bronchophony
• egophony
• • Whispered pectoriloquy

Question 19

consolidation causes

Answer 19

• pneumonia, TB

Question 20

increased and decreased tactile fremitus

Answer 20

• decreased or absent in conditions that impede sound transmission,
  such as COPD or a thick chest wall
• increased in conditions that increase sound transmission, such as
  pneumonia

Question 21

expected breath sounds

Answer 21

• Bronchial sounds: Auscultate over the trachea
• Bronchovesicular sounds: Auscultate over the
  bronchi
• Vesicular sounds: Auscultate over the lung fields

Question 22

Bronchial breath
sounds

Answer 22

Loud, high-
pitched sounds heard
over the trachea and
larynx

Question 23

Bronchovesicular
sounds

Answer 23

Medium-pitched
sounds heard over the
major bronchi

Question 24

Vesicular breath
sounds

Answer 24

Soft, low-
pitched, rustling sounds
heard primarily during
inspiration. They are
produced by air flowing
through small airways
(bronchioles

Question 25

abnormal breath sounds

Answer 25

Hyperresonance and absent breath sounds may indicate hyperinflation due to the presence of a pneumothorax or collapsed lung. Dullness may indicate diminished air exchange

Question 26

Adventitious (extra) Lung Sounds

Answer 26

Discontinuous sounds (not constant – come and go)  Crackles—fine  Crackles—course  Atelectatic crackles  Pleural friction rub

Question 27

Crackles—fine

Answer 27

short, high-pitched lung sounds that are sometimes described as crackling, bubbling, or clicking cause: congestive heart failure, pulmonary fibrosis, atelectasis, pneumonia, and pulmonary edema

Question 28

Crackles—course

Answer 28

low-pitched and moist, like pouring water out of a bottle. sign of asthma, congestive heart failure, pneumonia, and pulmonary edema. - louder and longer - can clear after coughing indicate fluid in lungs

Question 29

Atelectatic crackles

Answer 29

fine, discontinuous, high-pitched sounds heard during inspiration when small airways in the lungs reopen after being collapsed - caused by alveolar collapse

Question 30

causes for alveolar collapse

Answer 30

 Blockage of airways by mucus, blood clots, or tumors  Lack of surfactant (a substance that keeps alveoli open)  Prolonged bed rest  Postoperative surgery

Question 31

Pleural friction rub

Answer 31

- grating, creaking, or squeaking sound heard during breathing - caused by Inflammation of the pleura (pleuritis), Pneumonia, Pulmonary embolism, Tuberculosis, Lung cancer, and Asbestosis - sometimes with pain and SOB

Question 32

Wheeze—sibilant

Answer 32

Musical sound, squeak heard during inspiration or expiration  Usually louder during expiration

Question 33

Wheeze—sonorous rhonchi

Answer 33

Loud, low, coarse sound, similar to a snore; heard continuously during inspiration or expiration  May clear with cough  Usually due to mucus accumulating in trachea or bronchi

Question 34

stridor

Answer 34

high-pitched, noisy breathing sound caused by a narrowed or obstructed upper airway (inspiration)

Question 35

normal findings hearing tests

Answer 35

Rinne’s test is positive (indicating air conduction is better than bone conduction) and Weber’s is heard in the midline, whisper test is neg - inner ear / nerve problem

Question 36

conductive hearing loss test findings

Answer 36

Rinne’s test is negative (indicating bone conduction is better than air conduction) on the affected ear and Weber’s test localises to the affected ear - middle/outer ear problem

Question 37

sensorineural hearing loss test findings

Answer 37

Rinne’s test is positive (indicating air conduction is better than bone conduction) and Weber’s is heard in the unaffected ear. - inner ear / nerve problem

Question 38

go through heart motions

Answer 38

whiteboard

Question 39

s3

Answer 39

* Heard early in diastole, after the S2 * Best heard with the bell of the stethoscope placed at the apex (tip) of the heart * May be louder when the patient lies on their left side *can be normal in young adults, also signifies mitral regurgitation and heart failure

Question 40

s4

Answer 40

additional, extra heart sound that occurs during late diastole, just before the first heart sound (S1). It is characterized by a low- pitched, gallop-like sound. Causes: An S4 heart sound typically indicates increased resistance to ventricular filling during diastole. Left ventricular hypertrophy (enlarged heart muscle), Aortic stenosis (narrowing of the aortic valve), Myocardial infarction (heart attack), Hypertension, and Diastolic heart failure

Question 41

Gallops

Answer 41

extra low-pitched heart sounds – S3 and S4 (depends on when you hear it)

Question 42

Mitral snaps

Answer 42

heard when a thickened, diseased mitral valve opens - may be secondary to rheumatic heart disease. This sound results from diseased valves sticking together and making a snapping noise once they are forced open by blood flow.

Question 43

Ejection click

Answer 43

a sharp, high-pitched sound; it's an extra systolic sound heard best when the patient leans forward and the heart is closer to the chest wall. It is caused by mitral valve prolapse (leaflets bulge into atrium)

Question 44

Friction rub

Answer 44

a scraping sound heard that is caused by irritation and inflammation of the parietal and visceral layers of the pericardium (heart tissue). A scratchy or rubbing sound that is louder with exhalation and when the patient leans forward. The sound occurs during contraction. The rub is best heard during the maximal movement of the heart - atrial systole, ventricular systole, and the filling phase of early ventricular diastole

Question 45

Murmurs

Answer 45

whooshing sound resulting from the turbulent flow of blood through the heart and large vessels, often caused by incompetent valves. Murmurs may sometimes be felt on palpation

Question 46

Heart Murmurs: Grades

Answer 46

Grade I murmur  Barely audible  Heard only after listener "tunes in" Grade II murmur  Clearly audible, faint, but heard immediately Grade III murmur  Moderately loud, relatively easy to hear with a thrill Grade IV murmur  Loud, with a palpable thrill Grade V murmur  Very loud with a palpable thrill and can be heard with the rim of a stethoscope Grade VI murmur  Loudest, audible without touching the stethoscope to the patient’s chest