Abdomen
RUQ
Name 3 illnesses associated with overnutrition.
obesity, increasing risk for cardiovascular, type 2 diabetes, hypertension, cancer, gallbladder disease, sleep apnea, immune system disorders
Which is not a "normal" sign of aging in the elderly client?
Falls
What value does the nurse give a client who opens their eyes spontaneously when assessing the Glasgow Coma Scale?
4
What does the "A" represent in the acronym "BEFAST" when assessing for stroke?
Arms
What position should the nurse place the client in for an abdominal assessment?
Supine
What common labs are used to monitor nutritional status?
Albumin, prealbumin, cholesterol, A1c, glucose, hemoglobin.
A nurse is assessing a client with hemiplegia; what muscle strength grade would this client receive?
Grade 5: Full ROM against gravity, full resistance
Grade 4: Full ROM against gravity, some resistance
Grade 3: Full ROM with gravity
Grade 2: Full ROM with gravity eliminated (passive motion)
Grade 1: Slight contraction
Grade 0: No contraction
What is the maximum number a client can receive on a GCS assessment?
14
Which type of stroke is treated with TPA?
Ischemic. TPA dissolves blood clots and is contraindicated with hemorrhagic strokes.
What is the order for the abdominal assessment?
Inspection, auscultation, palpation, (percussion).
What are three risk factors of poor nutrition?
D.E.T.E.R.M.I.N.E
What is the name of the structure where two or more bones meet?
Joint
What is the priority intervention for a client whose pupils are not equal in size?
Call the healthcare provider.
What is the name of the stroke scale most commonly used in assessing a client suspected of having a stroke?
NIHSS
What are three risks for peptic ulcer disease (need to know but will not be on the exam).
NSAIDs, H. Pylori, excessive alcohol intake, smoking cigarettes, uncontrolled stress
Name 3 symptoms of anaphylactic shock.
obstructive swelling of lips, tongue, and/or throat; dysphagia, cyanosis, dyspnea, hypotension, feeling faint, confused, weak, passing out; level of consciousness; chest pain; weak or “thready”
pulse; a sense of “impending doom
Which part of the body can perform pronation and supination?
Which cranial nerves are both Motor and Sensory?
Some Say Marry Money But My Brother Says Big Brains Matter Most.
A client who has right-sided weakness likely had a stroke in which side of the brain?
Left. (The symptoms appear on the opposite side of where the stroke occurs.)
Which test is used to assess for ascites?
Fluid wave test.
What is the most common measurement used to
determine the extent of abdominal visceral fat in relation to body fat?
Waist circumference
What is the general term for the cracking or popping sound made by a joint?
Crepitus
How do you assess cranial nerve XI
Gag reflex and having the client say ahhh (uvula rising).
What is the priority nursing intervention for a client with dysphagia (difficulty swallowing)?
Aspiration precautions.