Nursing Assessment – Review

This is the effort of The Boss Academy to provide high quality study materials & model question papers for all competitive Nursing exams. Utilize our small effort & share to others to brighten Nursing profession. And we welcome your most valuable suggestions to improve our services & help us to do it best way to spread knowledge, skills & power.

Nursing Assessment – Review

1. Which cranial nerves control the extraocular muscles (EOM)?

Oculomotor (II),

Abducens (VI),

Trochlear (IV)

2. Documenting Heart Sounds

Frequency/Pitch

Intensity/Loudness

Duration

Timing: systole/diastole

3. Striae which occur when elastic fibers in the reticular layers of the skin are broken after rapid or prolonged stretching, have a distinct color when of long duration. What is this color?

Silvery White

4. Keloid

hypertrophic scar, elevated skin by excess scar tissue

5. What 4 areas do you auscultate when listening to the heart?

Aortic (2nd Rt, ICS)

Pulmonary (2nd Left, ICS)

Tricuspid (Lt lower sternum)

Mitral (5th ICS mid clavicle)

6. Cranial Nerve Mnemonic Sensory, Motor or Both

Some Say Marry Money But My Brother Says Bad Business Marry Money

7. Osteoarthritis

Degeneration of joint cartilage and the underlying bone, most common from middle age onward. It causes pain and stiffness, especially in the hip, knee, and thumb joints.

8. Polycyclic

i.e. psoriasis, angular lesions grow together

9. Define a Lymph Node

Small oval clumps of lymphatic tissue located at intervals along the vessels.

Filter fluid before returned to bloodstream remove harmful organisms.

10. Which of the following options is not a change that comes with menopause?

The vaginal pH becomes more alkalotic

The vagina becomes shorter and narrower

The cervix shrinks

The ovaries hypertrophy

11. Scale

Compact flakes of skin

12. During assessment of the spine, what do you ask the patient?

Flex

Extend

Abduct

Rotate

13. Characteristics of Osteoarthritis?

Joints ache and may be tender but have little or no swelling.

Symptoms often begin on one side of the body and may spread to the other side.

Onset develops slow over the years

Meta-tarso-phlangeal joint

Redness, swelling, heat, tenderness

metabolic disorder, elevated serum uric acid

More predominant in men older than 40 yrs

14. A murmur heard after S1 and before S2 is classified as

Systolic (possibly benign)

15. Zosteriform

Linear around unilateral nerve

ex: herpes

16. Moving the sole of the foot outward at the ankle

Eversion

17. A patient is admitted with diabetes mellitus, has a glucose level of 380 mg/dl, and a moderate level of ketones in the urine. As the nurse assesses for signs of ketoacidosis, which of the following respiratory patterns would the nurse expect to find?

Kussmaauls Respirations

The lungs try to compensate for the acidosis by blowing off volatile acids and carbon dioxide. This leads to a pattern of Kussmaul respirations, which are deep and nonlabored.

18. If someone has diabetes but not ketoacidosis they are

Hypokalaemia

19. Confluent Lesion

Ex hives//uriticaria

20. The nurse assess a patient with osteoarthritis, what would be an expected sign/symptom?

Stiff knees, hips, fingers, and vertebrae

21. Moving the arm in a circle around the shoulder

Circumduction

22. Melena

Really dark stools b/c of blood

23. Discrete lesion

Skin tags//acne

24. 3 areas of the Glasgow Coma Scale

eye opening

motor response to stimuli

verbal response

25. Swan-neck, boutonnière deformity, and ulnar deviation are conditions associated with

Rheumatoid arthritis

26. Cerebellar function is assessed by which of the following tests?

Coordination, hop on one foot

27. Often seen with history of trauma or obesity, and can be genetic

Osteoarthritis

28. Arterial Insufficiency Characteristics

coolness/pallor

Diminished pulses

shiny, thin skin

well defined edges NO bleeding

pale ischemic base

occur at toes, heels, lateral ankle

29. Cranial Nerve Mneumonic

(Oh Oh Oh To Touch And Feel Very Good Velvet AH!)

One Of Our Tamil Teacher Asked For Very Good Vada And Halwa

Olfactory

Optic

Oculomotor

Trochlear

Trigeminal

Abducens

Facial

Vestibulocochlear

Glossopharyngeal

Vagus

Accessory

Hypoglossal

30. What is the parietal lobe concerned with?

post-central gyrus

primary center for sensation

31. An area of the body that is supplied mainly from one spinal segment through a particular spinal nerve is identified as a:

Dermatone

32. Why are children more at risk for ear infections?

They have shorter, wider, more horizontal Eustachian tubes

33. Each half of the cerebrum is a

Hemisphere

34. Characterized by hard, non-tender nodules, 2 to 3 mm or more

Osteoarthritis

35. Wheal

Urticaria-hives

raised irregular shape due to edema

mosquito bites, allergies

26. Control of body temperature

Hypothalamus

27. Macule

Patch larger than 1 cm

flat not raised

28. Where is S1 louder than S2

at the apex

29. Temporal Lobe Function?

Auditory reception center

Hearing, taste, and smell

Wernicke's Area= language comprehension

30. This occurs when the pulmonic valve stays open a little bit longer during inspiration.

Split S2 (lub-T-dub)

31. Objective Findings for Osteoarthritis

Limited ROM in the affected joint

fluid is easily moved around the joint space

32. Turning the forearm so the palm is out

Pronation

33. Subjective Data for Osteoarthritis

Pain (worse later in the day)

stiffness

reported limited ROM

34. When is the best time to perform a breast self examination?

on the 4th - 7th day of the cycle

35. Papule

Plaque larger than 1 cm

can feel, slightly elevated

mole wart

36. Signs/Symptoms of Hemorrhoids

Swollen and inflamed veins in the rectum and anus that cause discomfort and bleeding

Painless flabby papules, varicose vein of the hemorrhoidal plexus

Occurs from straining at stool, pregnancy, obesity, liver disease, or low fiber diet.

37. A 78 year old male comes into the office and the nurse assesses that he has a greying/white arc/circle around his cornea with no vision loss. She should conclude that the patient has:

Arcus Senillis

38. Moving the body part forward and parallel to the ground

protraction

39. A newborn’s nail beds may be blue (cyanotic) for the first few hours of life, then they turn what color?

pink

40. Neurological Changes in the Older Adult

loss of muscle bulk

general atrophy

nerve conduction decrease 5-10%

Slower Reaction Time

Touch, Smell Taste, Pain sensation diminished

decrease blood flow / oxygen

41. Vesicle

Bulla- larger than 1cm

a blister, herpes chicken pox, shingles

42. Turning the forearm so the palm is up

supination

43. What is the function of the occipital lobe?

Visual Receptor Center

44. What is the best position for inspecting the breasts for retraction?

Sitting with hand pushing onto hips

45. Signs/Symptoms of Fecal Impaction

Decreased Bowel Motility

A collection of hard, desiccated feces in the rectum

May complain of constipation or of diarrhea as a fecal stream passes around the impaction

46. Venous Insufficiency Characteristics

Brawny edema

brown pigment deposits

pulses are normal

Bleeding uneven edges

47. Straightening a limb at a joint

extension

48. RAM

Roy's Adaption Model

the individual as a set of interrelated systems (biological, psychological and social).

strives to maintain a balance between these systems and the outside world,

49. During neurologic examination the tendon reflex fails to appear. Before striking the tendon again, the examiner might use what type of technique?

reinforcement

50. Bending a limb at a joint

Flexion

51. Influences Body Temperature

Diurnal Cycle

52. Where is the most common site for breast tumors

upper outer quadrant

65. Moving a body part backward and parallel to the ground

Retraction

53. Dehydration Assessment

Dry mucous membranes

lips cracked

Skin is fissured

Tenting w/ turgor

54. skin normal findings seen mostly in infants?

Cafe Au Lait Spot

Mongolian Spot

Lanugo

55. Which of the following vital signs are characteristic of an aging adult?

Decreased temperature

Decreased sweating

Increased risk of orthostatic hypotension

56. What are the 4 main lymph nodes accessible to inspection and palpation?

Cervical Node

Axillary Node

Epitrochlear Node

Inguinal Node

57. How often should males 15 yrs > do a testicular self exam?

Once a month

58. What is genu valgum?

Knocked Knees

59. Older Adult Expected Finding During Breast Exam

lactiferous ducts are more palpable

feel firm and stringy b/c of fibrosis and calcification.

60. What does a “normal” tympanic membrane look like?

Shiny, translucent, pearly grey

61. An Area not commonly associated with pain

Intramuscular

62. The nurse is teaching a community class to people with Type 2 diabetes mellitus. What is the explanation for that?

Cells become resistant to circulating insulin

Normally insulin binds to special receptor sites on the cells and initiates a series of reactions involved in metabolism. In Type 2 diabetes these reactions are diminished primarily as a result of obesity and aging."

63. Care for DKA

Fluid/electrolyte imbalance

normal saline 0.45%

blood glucose level

acidosis

IV insulin

64. If a diabetic has ketoacidosis what will potassium be?

hyperkalemia

hypovolemia

Renal failure

65. What angle do you hold the needle for an average sized subcutaneous injection?

45 degrees

66. Explain polyphagia for diabetes

We get hungry because our cells are starving for energy.

67. This type of illness is sudden.  It can last 3-6 months. It can also be reversed

Acute Illness

68. A blood sugar is well controlled when haemoglobin A1c is what percentage?

7%

69. Nursing Diagnoses for patient with VTE

Ineffective Peripheral Tissue Perfusion

Acute Pain

Risk for impaired physical mobility

Risk for Embolization

Impaired Skin Integrity

70. When administering an intradermal injection, what angle should the nurse position the needle for insertion?

5-15 degrees

71. What is the oxygen concentration for a Resuscitation mask w/ oxygen inlet (simple mask)?

35-55%

6-15 LPM

Victims who are NOT breathing, or difficulty breathing

72. Clinical Manifestations for Hypervolemia?

Pulse is bounding JVD

High BP

Tachypneic

dyspnea

crackles

headache, confusion, muscle spasms

Anorexia, weight gain, ascites

peripheral edema

74. How far should the drip chamber be filled?

1/3 -1/2 full

75. "What insulin type can be given by IV?

Regular Insulin

76. Nodule

tumor larger than 3 cm

77. What is the Frontal Lobe concerned with?

Personality

Behavior

Emotions

Intellectual Function

Broca's Area- Motor Speech

78. Wheal

Urticaria-hives

raised irregular shape due to edema

mosquito bites, allergies

79. Pronation and supination of the hand and forearm are the result of the articulation of the

Radius

Ulna

80. Characteristics of rheumatoid arthritis?

Joints are painful, swollen, and stiff.

It often affects small and large joints on both sides of the body (symmetrical)

Onset is rapid

Begins at any time in life

81.Describe a Non-tunneled CVAD

inserted directly into a central vein and is associated with a higher risk of infection

either the chest or the neck

can be inserted quickly at the bedside

Dwell Time less than a month

82. Non-pharmacological interventions for pain

Reposition

massge

Heat/Cold compress

Distraction

Elevation

Humor

83. Normal Value for Chloride

95 - 107 mEq/L

84. What symptoms might an older woman with diabetes mellitus complain?

perineal itching

Rationale: Older women might complain of perineal itching due to vaginal candidiasis.

85. Nursing diagnosis for a patient with advanced respiratory diseases.

Hyperthermia Related to Infectious Illness,

ineffective airway clearance,

pneumonia

pulmonary embolism

Activity Intolerance

Inadequate Nutrition

Social Isolation

Impaired Gas Exchange.

Anxiety.

Risk for Infection

Ineffective Coping

Fatigue.

Ineffective Breathing Pattern

Insomnia

86. Name 4 examples of an acute illness?

Pneumonia

Delirium

Shingles

Apendicitis

87. What is the oxygen concentration for a nasal cannula?

24-44%

1-6 LPM

Victims w/ difficulty breathing, unable to tolerate mask

88. Glucose Value 2 hours after eating

Up to 140

89. Labs for someone with metabolic acidosis

low pH low HCO3

90. Name the primary veins for peripheral IV insertion

cephalic, median, cubital, basilic

91. Left Sided Heart Failure

Most Common

Pulmonary Congestion

Crackles

Poor Oxygenation

S3, Increase Afterload

Irregular Palpitations

Pulmonary Edema

Diastolic and systolic dysfunction

Blood backing up into right atria

92. What does insulin do to potassium level

push potassium back into the cells,

93. What is a good diabetic meal plan

guidelines for how we are all supposed to eat

focused on the amount of carbohydrates.

94. Clinical Manifestations for a patient with Venous Insufficiency

Pooling of blood in the legs

Damage to valves in the veins

Eczema

Edema

Leathery brown skin

95. 5 Reasons a nurse would avoid an area of the hand or arm for IV insertion

Impede ADL's

Tender, Red, Rash, Infected

Paralysis, Dialysis, Shunt or Mastectomy

Site distal to previous venipuncture

Distal to sclerosed, hardened, or phlebitic veins

96. An acute metabolic condition, usually is caused by absent or markedly decreased amounts of insulin

Diabetic ketoacidosis

97. Diabetes Mellitus Type 1- Signs & Symptoms

3P's

Polydipsia (thirst)

Polyuria (urine)

Polyphagia (hunger)

98. Characteristics of Circulatory Overload

Excessive amounts of isotonic/hypertonic solution

Too Rapid

Overload is associated w/ increased risk of death

99. Diagnostic Testing for Heart failure

BNP

ANP

Creatnine Kinase

Troponin

Fibronogen

Chest Xray

EKG

Coronary Angiogram

Echogram

100. What is the highest priority for a patient with DVT or VTE

Skin Integrity b/c of amputation risk

Thanks

Visit our sites for more updates

www.thebossacadmy.net for study materials, model previous year question papers, books & journals

www.medjobss.com for all medical related professional Government jobs, notification, application &  apply online links.