NURS-B 244 exam 1 Latest Update 2023- 2024 242 Questions and Verified Correct Answers Guaranteed A+
abnormal birthmarks - Correct Answer: nevus flameus, strawberry hemangioma,
cavernous hemangioma
active listening - Correct Answer: listening with a purpose
Verbal and non-verbal messages Focus on patient's response
acute pain - Correct Answer: Recent onset (less than 6 months)
Result of tissue damage Self-limiting Physiological signs Elevated HR Elevated RR
adolescences - Correct Answer: range:60-90 bpm
average: 70 bpm
Adolescent blood pressure - Correct Answer: pre-hypertension SBP/DBP between
120/80
adolescent BP expectation - Correct Answer: Systolic range 94-139
Diastolic range62-88
adolescent RR - Correct Answer: 12-16
adult - Correct Answer: range: 60-100 bpm
average: 70 bpm
adult RR - Correct Answer: 12-20
Adult/pregnant/older BP expectation - Correct Answer: Systolic range 110-139
Diastolic range 60-79
alopecia areata - Correct Answer: Chronic inflammatory disease of hair follicles Unknown cause- believe autoimmune disorder, metabolic disease and stressful events Multiple round patches of hair loss Poorly developed shaft breaks and grows back in 3-4 months (some suffer total scalp hair loss)
anatomic-physiologic differences - Correct Answer: newborns have thinner more
permeable skin than older children and adults 1 / 4
Heat and cool quickly Newborn and young infants have decreased subcutaneous fat and a large body surface area which can lead to thermoregulation problems Apocrine sweat glands and sebaceous gland activity increases in adolescents resulting in oiler skin and acne
arterial insufficiency - Correct Answer: any condition that slows or stops the flow of blood through arteriesOne of the most common causes of arterial insufficiency is
atherosclerosis or hardening of the arteries:
Blood flow may be completely stopped if a blood clot lodges in a narrowed area.
arterial insufficiency symptoms - Correct Answer: Absence of hair but no enough
perfusion to support hair growth Shiny, dry skin, pale Cooler skin temperature Minimal or No edema Dependent rubor (a fiery to dusky red color when the leg is in a dependent position.Extremity is still cool). No aterial blood flow, wont have the warm touch Ulcerations on heel or toes (circular) Diminished or absent pulses Thickened nails Intermittent Claudication (cramping in the legs induced with activity or exercise)
aterial insufficiency throughout the body - Correct Answer: Symptoms depend on where
your arteries become narrowed:
If it affects your heart arteries, you may have chest pain or a heart attack.If it affects your brain arteries, you may have a stroke.If it affects the arteries that bring blood to your legs, you may have frequent leg cramping when you walk.If it affects the arteries in your belly area, you may have pain after you eat.
atopic dermatitis - Correct Answer: Associated with hay fever and asthma
May be familial More common in infancy and childhood
auscultation - Correct Answer: Listening to sounds in the body
Audible to ear (don't need stethoscope) Stridor, severe wheezing, abdominal gurgling Stethoscope (clean between patients) Blocks extraneous sounds Necessary to hear heart, blood vessels, lungs, and intestines Listen for intensity, pitch, duration and quality Place directly on the skin Tips for success Don't bump stethoscope tubing (12-18") Chest hair may interfere 2 / 4
Close your eyes Quiet environment
auscultation BP measurement - Correct Answer: Blood flows freely until inflated cuff occludes artery and silences sounds As pressure is released listen for Korotkoff sounds (clear rhythmic thumping) 1st Kortokoff sound is SBP- 1st sound 5th Kortokoff sound is DBP-when the sounds disappears
Automated Blood Pressure Monitoring - Correct Answer: Korotkoff sounds not
auscultated Monitor senses circulating blood flow vibrations and converts to electric impulses Accuracy concerns Accurate cuff placement/size, calibration, SBP generally consistent/DBP accuracy is not clear (When in doubt recheck using auscultation method)
axillary - Correct Answer: Place probe in middle of axilla
Poorly reflects core temperature (not close major blood vessels) Temperatures are 1 degree lower than oral temperatures
basal cell carcinoma - Correct Answer: Most common form of skin cancer
Affects light skinned individuals between 40-80 Locally invasive and rarely metastasizes More commin in males than females Nodular pigmented lesion with depressed center and rolled borders and/or central ulceration in areas of sun or UV exposure
bell - Correct Answer: Concave in shape
Used to hear soft, low-pitched sounds: extra heart or vascular sounds (bruit)
Press very lightly - just enough pressure to ensure contact with the skin and a complete seal around the edge If pressed too firmly functions as a diaphragm
biographic data - Correct Answer: collected first visit, won't need to update unless there is change -help form complete picture of patient as unique individual
birth marks - Correct Answer: congenital dermal melanocytosis, cafe au last spot, telangiectasis/flat capillary hemangioma
bites - Correct Answer: Always intentional and commonly associated with abuse
Ovoid with tooth imprints may or may not break skin Note size to determine if by child or adult Infant and children commonly on buttocks/genitals
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black widow - Correct Answer: Found throughout U.S.
Minimal symptoms at time of bite Erythemia with two red puncta Within hours severe abdominal pin and fever
Blood pressure assessment - Correct Answer: Direct B/P
Invasive procedure- insertion of catheter into artery Continuous measurement and arterial waveforms (critical care) Indirect B/P Manual B/P -auscultation of sounds using sphygmomanometer Automated B/P- AKA oscillometric B/P - detection of blood flow vibrations Typically taken in upper arm If upper arm not available an ankle B/P is preferred to calf B/P SBP is generally 10-40 mm Hg higher in leg than arm Wrist and finger B/P not recommended in clinical practice setting r/t lack of accuracy
BP abnormalities - Correct Answer: Orthostatic B/P
B/P taken in lying, sitting and standing positions Drop of SBP 20-30 mm Hg when changing positions (lying to sitting or sitting to standing) is positive for orthostatic B/P Nursing Diagnosis: Impaired central perfusion r/t (anxiety, exercise, smoking, caffeine, heart disease etc.) AEB SBP of 168
Goal: Blood pressure within expected range for age
Planning: Does patient require blood pressure medication? Is it ordered for the patient?
Implement: Give the ordered blood pressure medication
Evaluate: Recheck the B/P in 60 minutes. Is B/P lowering?
BP expectation new born - Correct Answer: Systolic Range 60-90
Diastolic Range 20-60
brachial pulse - Correct Answer: used in CPR and cap refill for infants/small children) Palpate groove between biceps and triceps just medial to bicep tendon at the antecubital fossa
Brown reculse - Correct Answer: Found in central and south central U.S.
Minimal symptoms at time of bite Initial lesion with erythema and edema evolving into necrotic ulcer with erythema and purpura Other symptoms include fever, nausea and vomiting
bruise - Correct Answer: Frequently associated with abuse
Most common is immersion burn "glove" or "stocking" patterns Contact burn- leave impression of object (cigarette, light bulb, etc.) Accidental burns leave glancing burn pattern with non uniform pattern
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