Study Guide

Question 1

What is subjective data in nursing assessment?

Answer 1

Information the patient reports (e.g., pain level, dizziness, nausea).

Question 2

What is objective data in nursing assessment?

Answer 2

Observable/measurable findings (e.g., vital signs, lab results, skin integrity).

Question 3

What does the Braden Scale assess?

Answer 3

Pressure ulcer risk based on sensory perception, moisture, activity, mobility, nutrition, and friction/shear.

Question 4

What is the score range for the Braden Scale?

Answer 4

6-23 (lower scores indicate higher risk).

Question 5

What does the ‘A’ in the ABCDE of Melanoma stand for?

Answer 5

Asymmetry.

Question 6

What does the ‘B’ in the ABCDE of Melanoma stand for?

Answer 6

Border irregularity.

Question 7

What does the ‘C’ in the ABCDE of Melanoma stand for?

Answer 7

Color variation.

Question 8

What does the ‘D’ in the ABCDE of Melanoma indicate?

Answer 8

Diameter >6mm.

Question 9

What does the ‘E’ in the ABCDE of Melanoma indicate?

Answer 9

Evolving shape/size.

Question 10

What are vesicles?

Answer 10

Small, fluid-filled blisters (e.g., herpes, chickenpox).

Question 11

What are bullae?

Answer 11

Large vesicles (>5mm, e.g., burns, blisters).

Question 12

Define papules.

Answer 12

Raised, solid lesions (e.g., warts, moles).

Question 13

What are wheals?

Answer 13

Raised, red, itchy patches (e.g., hives).

Question 14

What does cyanosis indicate?

Answer 14

Bluish skin discoloration (hypoxia).

Question 15

What is ecchymosis?

Answer 15

Bruising due to bleeding under the skin.

Question 16

What are petechiae?

Answer 16

Tiny red spots from capillary bleeding.

Question 17

What is a cherry angioma?

Answer 17

Small, red, benign skin growths.

Question 18

Define eczema.

Answer 18

Chronic inflammatory skin disorder.

Question 19

What is impetigo?

Answer 19

Contagious bacterial skin infection.

Question 20

What is onychomycosis?

Answer 20

Fungal nail infection.

Question 21

What does PERRLA stand for in eye assessment?

Answer 21

Pupils Equal Round Reactive to Light Accommodation.

Question 22

What does the Snellen Chart assess?

Answer 22

Distance vision (20/20 normal).

Question 23

What does the Rosenbaum Chart test?

Answer 23

Near vision.

Question 24

What is the purpose of the Ishihara Test?

Answer 24

Screens for color blindness.

Question 25

List the normal types of breath sounds.

Answer 25

* Vesicular * Bronchial * Bronchovesicular

Question 26

What are abnormal breath sounds?

Answer 26

* Crackles (fluid) cruching * Wheezing (narrowed airways)high pitched musical * Stridor (obstruction)high pitched whistling

Question 27

What is Cheyne-Stokes respiration?

Answer 27

Periods of deep breathing alternating with apnea.

Question 28

What does Kussmaul breathing indicate?

Answer 28

Deep, rapid breathing (DKA, metabolic acidosis).

Question 29

Define tachypnea.

Answer 29

Fast breathing >20 breaths/min.

Question 30

Define bradypnea.

Answer 30

Slow breathing <12 breaths/min.

Question 31

What is dyspnea?

Answer 31

Shortness of breath.

Question 32

What are club fingers associated with?

Answer 32

Chronic hypoxia (e.g., COPD, heart disease).

Question 33

What is tripod positioning?

Answer 33

Patient leans forward, using arms to support breathing effort.

Question 34

What does tripod positioning indicate?

Answer 34

Respiratory distress (e.g., COPD, asthma).

Question 35

What are normal lung assessment findings?

Answer 35

Clear breath sounds, symmetrical chest rise.

Question 36

What are abnormal lung assessment findings?

Answer 36

* Wheezing (asthma, COPD) * Crackles (CHF, pneumonia) * Diminished breath sounds (atelectasis)

Question 37

What does the 'O' in OPQRST stand for?

Answer 37

Onset: When did it start?

Question 38

What does the 'P' in OPQRST refer to?

Answer 38

Provocation: What makes it worse?

Question 39

What does the 'Q' in OPQRST refer to?

Answer 39

Quality: Describe the pain.

Question 40

What does the 'R' in OPQRST stand for?

Answer 40

Radiation: Does it spread?

Question 41

What does the 'S' in OPQRST indicate?

Answer 41

Severity: Pain scale 0-10.

Question 42

What does the 'T' in OPQRST refer to?

Answer 42

Time: How long has it lasted?

Question 43

What does OLDCARTS stand for?

Answer 43

* Onset * Location * Duration * Characteristics * Aggravating factors * Relieving factors * Treatment * Severity

Question 44

What is a normal thyroid assessment finding?

Answer 44

Smooth, non-enlarged thyroid.

Question 45

What are signs of hyperthyroidism?

Answer 45

* Weight loss * Tachycardia * Heat intolerance

Question 46

What are signs of hypothyroidism?

Answer 46

* Fatigue * Weight gain * Cold intolerance * Bradycardia

Question 47

What characterizes Stage 1 pressure ulcers?

Answer 47

Red, non-blanchable skin.

Question 48

What characterizes Stage 2 pressure ulcers?

Answer 48

Partial-thickness skin loss, blister-like.

Question 49

What characterizes Stage 3 pressure ulcers?

Answer 49

Full-thickness skin loss, subcutaneous fat visible.

Question 50

What characterizes Stage 4 pressure ulcers?

Answer 50

Muscle, bone, or tendon exposed.

Question 51

What is the definition of a macule

Answer 51

A small circular flat spot less than 1mm to 1cm in diameter. ( freckles)

Question 52

Bronchi

Answer 52

Low pitched snoring

Question 53

Bronchial

Answer 53

High pitched hollow , tubular sounds