NR302 weeks 3, 4, 5-exam 2

What is vital?

100

What type of temperature is most accurate but most invasive? 

Rectal

200

Caused by prolonged exposure to cold

Hypothermia

300

Press lightly below the base of the thumb

Radial pulse

400

A 78 y/o with a pulse of 140 bpm

Tachycardia 

500

Sitting BP 148/76 and standing BP 100/54

Orthostatic hypotension 

600

A 46 y/o with a respiratory rate of 32

tachypnea 

Skin-tastic!

100

yellowish color of the skin

Jaundice 

200

Paleness of the skin

pallor

300

How to check temperature 

Use the back of your hand and palpate the body bilaterally

400

Can check this to look for possible dehydration

skin turgor

500

Blister, fluid-filled sac example varicella 

Vesicle

600

skin is broken and extends into subcutaneous fat layer, what stage?

stage 3

Let's see & hear

100

double vision/seeing two of something

Diplopia

200

Constriction of pupils when bright light shined in

Pupillary Light Reflex

300

Normal pupil size

3-5 mm

400

PERRLA

pupils equal round and reactive to light and accommodation 

500

Inspection of tympanic membrane

◦Translucent, pearly gray

600

When inspecting internal ear with otoscope how should pinna be manipulated adult vs child

Pull pinna up and back for adults, 

down and back for kids.

Let's smell & taste

100

purpose of nose

filters air, smell

200

Examine the nose

symmetry, inflammation, patency  

300

Floor of the mouth under the tongue

Sublingual

400

test patency of nares

Have client occlude each nostril and breathe in

500

assess Uvula

Open mouth say "ahh" look for midline

600

Risk factor for Oral and pharyngeal cancers

smoking

What's up with the head & neck

100

Risk factors for head & neck injury

No safety equipment, alcohol/drug use

200

What to palpate on the neck

trachea and lymph nodes 

300

Is the trachea ....

Midline

400

The two approaches to assess the thyroid

anterior and posterior approach 

500

inspecting the head/neck for

symmetry, lumps, edema 

600

The purpose of lymph nodes

eliminate foreign substances/drains from tissues

Who's the priority?

100

Four patients in a long-term care facility:

• A. Elderly patient with dry mucous membranes and skin tenting.
• B. Patient with mild nausea, drinking fluids well.
• C. Patient with diarrhea, but normal skin turgor and alert.
• D. Patient with a low-grade fever and adequate urine output.

A--dehydration

200

Four patients in a busy clinic:

• A. Patient with BP 188/110, complaining of headache and blurry vision.
• B. Patient with BP 150/90, asymptomatic and scheduled for follow-up.
• C. Patient with BP 140/88, recently started antihypertensive medication.
• D. Patient with BP 160/95, requesting a refill for their medication.

A--hypertensive emergency

300

Four patients on a neuro unit:

• A. Post-stroke patient with left-sided weakness and slurred speech.
• B. Head trauma patient with dilated pupils and decreased level of consciousness.
• C. Seizure patient postictal, drowsy but arousable.
• D. Migraine patient requesting pain medication, alert and oriented.

B--increased ICP

400

Four patients arrive at triage:

• A. 45-year-old with chest pain relieved by antacids.
• B. 60-year-old with chest pain radiating to the jaw and diaphoresis.
• C. 30-year-old with anxiety and palpitations.
• D. 70-year-old with stable angina and normal vitals.

B--possible myocardial infarction 

500

Four post-op patients:

• A. 2 hours post-op with 8/10 pain, requesting meds.
• B. 6 hours post-op with no bowel sounds.
• C. 1 hour post-op with saturated dressing and BP 88/50.
• D. 4 hours post-op with nausea and vomiting.

C--possible hemorrhage  

600

Four telemetry patients:

• A. A-fib with HR 110, BP 130/80.
• B. Bradycardia with HR 48, asymptomatic.
• C. V-tach with pulse, BP 90/60.
• D. Sinus tachycardia HR 120 after walking.

C--V tach is unstable hr

Matters of the heart

100

create turbulent blood flow (like a swooshing sound)

Murmurs

200

bottom of the heart, 5th intercostal space, mid-sternal line

Apex

300

best position to assess for JVD (jugular venous distention)

lie supine and elevate the HOB 30-45 degrees

400

This vital sign is often the first indicator of cardiac distress.

heart rate

500

What is the difference between left and right sided heart failure

left sided-lung congestion

Right sided-dependent edema

600

name the valve and location of each heart sound auscultated 

Aortic - 2nd ICS R sternal border

Pulmonic - 2nd ICS L sternal border

Erb’s - 3rd ICS L sternal border

Tricuspid - 4th ICS L sternal border

Mitral - 5th ICS L MCL

•Apical impulse = 4th or 5th L MCL