Final Exam Study Guide

1. How would you assess someone with Heartburn?

 Ask about onset
o after eating = GERD
 Ask about types of food consumed (spicy foods)
 Assess breathing patterns, stomach irritation, burning of the esophagus
 Is pain relieved/worsen by sitting up/laying down?
o If pain is worse when lying down—
 assess for GERD
 palpate abdomen for hiatal hernia
 Type and location of pain
o Angina/Indigestion may indicate MI
o Left epigastrium pain = check for ulcers
 Do they experience sweating, radiating pain, or lightheadedness?

2. What would a cardiovascular assessment look like on a healthy individual?

 Heart sounds heard at all sites [APETM]
 patient breathes normally & then holds breath in expiration
 Inspect anterior chest wall
 Palpate apical pulse (1 min)
o Pulse: 60-100
 Auscultate S1/S2 heart sounds
o S1 louder at apex
o S2 louder at base
o S1 & S2 equally loud at Erb’s point
 Nail beds pink w/angle 160º
 Jugular pulsations visible without distention [p.239]

3. What are the risk factors for someone with hypertension? - select all that apply
 Age and race [African American]
 Lack of physical activity
 Poor diet [salt]
 Alcohol and/or tobacco
 Overweight/obesity
 Diabetes
 Fluid overload (hypervolemia) -- Edema
 Na+ retention--- Edema
 Renal failure
 Family history [p.213]

4. What other signs and symptoms would someone have with elevated jugular distension (JVD)?
 May see bounding carotid pulse
 Fluttering or oscillating pulsations
 Increased blood volume (hypervolemia)
 Right sided heart failure
 Hypertension and discrepancies in measurements of BP between arms [p.220-221]
 Irregular rhythms
5. What conditions would cause you to hear an S4 sound?
 Normal: children and young adults
 Indicates a “stiff” or non-compliant ventricle
 Hypertrophy of the ventricle precedes a non-compliant ventricle
 Coronary artery disease *major cause* [p.231]
 Hypertension
 Aortic stenosis

6. How would you open an interview with a patient?

 Phase 1: Introduce yourself
 Describe purpose of interview
 Describe interview process
 Establish rapport
 Describe what to expect and ~length of the interview
 Begin with general observation
 Initial impression will guide the interview
 Quiet, professional and private environment
 Ask open ended questions- to get the most information

7. How would you respond to a patient who says they do not take many meds?
 Respond by saying “what meds do you take?”
 Use the wording the patient uses
 Inquire about prescriptions and over the counter preparations
 Herbal treatments in addition to any home remedies
 Don’t assume prescription or recreational drug use, let the patient clarify what meds they do take
 The answer to this question is NOT the one that asks the patient to clarify whether the drugs are illicit or not

8. What kind of patient would get a focused assessment?

 Most common in walk-in, clinic, urgent care, or emergency dept. [p.3]
 Done on a patient coming in for a specific complaint-- the exam is limited to that specific complaint (pg. 3)
 A focused assessment focuses on specific system or systems involved in the patient’s problems
 Patient with a chief complaint, not multiple things going on at one time

9. How do you assess for abdominal fluid?

 Percussion: dull sounds when percussing the abdomen -- indicates ascites.
 Dull sound is also found over solid organs, like the liver and spleen.

10. How do you assess for kidney tenderness?

 Indirectly percuss for CVA tenderness and flank pain
 Can use direct and indirect percussion
 This question is asking specifically about HOW to perform CVA tenderness
o Which part of the hand do you use, ect.
 1. Ask the client to take a deep breath
2. Use palmar surface of hand
3. Strike surface with ulnar surface of dominant hand curled into a fist

11. What is tympany?

 Percussion sound heard over the abdomen
 Use non-dominate hand, use dominant hand to tap on non-dominant middle finger
o Have to know which finger to use, is it the TIP or the PAD of the finger?
 Use PAD of the finger

12. When do you use the bell of the stethoscope? The diaphragm?
 Stethoscope used to auscultate sounds within the body that are not audible with the naked ear
 Diaphragm- higher pitched sounds such as breath, bowel and normal heart sounds
 Bell- lower pitched sounds such as extra heart sounds or vascular sounds

13. What makes a BP reading inaccurate? Too high? Too low?

 Using the wrong size cuff can give you an inaccurate BP
 Crossing legs
 Elevated arm: specifics about having arm elevated? Low or high?
 If the cuff is too wide- BP will be low
 If the cuff is too narrow- BP will be high
 Both select all that apply questions; know specifics

14. What do you use a Doppler for?

 Uses ultrasonic waves to amplify sounds that are difficult to hear with an acoustic stethoscope
 Ex: fetal heart tones, peripheral pulses

15. How would you confirm an irregular radial pulse in a patient?

 Auscultate apical pulse for 1 min

16. What are the normal vitals across the lifespan?

 Newborn
o HR: 120-180 bpm
o RR: 30-60
o BP: 60-90/20-60
 Toddler
o HR: 90-140 bpm
o RR: 24-40
o BP: 80-112/50-80
 Child
o HR: 75-100
o RR: 18-30
o BP: 84-120/54-80
 Adolescent
o HR: 60-90
o RR: 12-16
o BP: 94-139/62-99
 Adult
o HR: 60-100
o RR: 12-20
o BP: 110-139/60-79
There were some lab values related to age, may want to review if you can find them anywhere? *rmr a ? about old man and ab/normal
lab values.

17. What are you hearing during systolic BP? Diastolic BP?
 Systolic- highest pressure exerted, 1st sound heard
o When ventricles are contracted-- blood is being ejected from the heart
 Diastolic- lowest pressure exerted, 2nd sound heard
o When ventricles are relaxed
 Regulated by baroreceptors

18. How would a Catholic patient respond to a Jewish patient who states that the nurse does not
understand/knows nothing about them?
 The nurse could ask the patient about their experiences to better illustrate what is of value to them and it will
characterize their culture, will help nurse better understand patient’s culture
 Provide patient centered care
 Culturally competent

19. How do you care for someone with different values?

 Accept and respect differences
 Inquire about differences to better understand the patient and their background
 Display an ability to respect patients as individuals regardless of their beliefs, values, and preferences
 Become aware of own biases and gain knowledge about various cultures
 Avoid stereotyping based on skin color or physical characteristics of a person

20. What does culturally centered care look like?

 Patient centered care
 Interact with patient to show interest in their culture, value and beliefs
 5 attributes that convey patient-centered, culturally competent care:
 Knowledge
 Consideration
 Understanding
 Respect
 Tailoring

21. How do you improve cultural awareness? - select all that apply
 Provide patient centered care
 Develop cultural competence
 Understand that an individual’s culture influences their perception, behavior, and evaluation of the world
 Understanding preferred communication practices and behaviors of a patient
 Remain sensitive and ask questions to gain information about the patient
 Understand the meanings of culture, ethnicity, race, spirituality, and religion

22. What is malignant pain?

 Pain caused by cancer cells in the body (chronic pain)

23. How can someone with an amputated limb still feel pain?
 “Phantom Pain”- pain felt in amputated extremity
 As a result of abnormal processing of sensory input
 This question was asking us to “dumb it down” for the pt; there are at least two answers that are correct—one is in
medical jargon and one is made for the pt to understand—do not use medical jargon, use terms pt can understand

24. What is pain tolerance?

 Duration and intensity of pain a person will endure before responding

25. What are the signs and symptoms of pain? - select all that apply
 Aching, throbbing, burning
 Does it interfere with daily life activities?
 Is it localized or all over
 Increases HR, RR, BP
 Change in facial expression (nonverbal sign)
 Threshold- point where stimulus is felt as pain

26. How do you access for pain? - select all that apply
 Pain is considered the 5th vital sign
 Pain is whatever patient tells you the pain is
 Acute- recent
 Chronic- ongoing
 Initial assessment of pain, reassessment of pain
 Onset, Location, Duration, Characteristics, Aggravating factors, Related symptoms, Treatments by patient, Severity
(OLD CARTS)
 0-10 pain scale- measures severity, intensity and strength of the pain
 Wong Baker Face Scale- for children 3 yrs or older
 A patient who cannot communicate- look at facial expressions, behaviors that indicate pain, analgesic trials
27. What kinds of patients and scenarios might cause anxiety?
 “Anxiety interferes with one’s ability to concentrate, learn and solve problems”
 Anxiety is more common in females
 May notice heart palpitations, uneasiness of the patient, emotional distress, or muscle tension
 Pain and stress can initiate anxiety
 Question with 4 different scenarios: one included a patient hitting the call bell every 5 minutes but cannot rmr if that
was the correct answer? Help?

28. What would cause an A, D, K vitamin deficiency in a patient?

 Decreased fat diet
 A, D, and K are fat soluble vitamins

29. What kinds of questions would you ask a patient who has gained or lost weight?
 Ask what medications they take
 Any change in diet, exercise or lifestyle habits
 Have there been any stressors
 Assess family weight history
 When did the weight gain/ loss start?
 What contributed to weight gain/loss?
 Symptoms involved with weight gain/ loss
 Was weight gain/ loss intentional?

30. What is a good tool to assess dietary intake?

 24-hour food recall

31. If you hear crackles during auscultation in the morning and they disappeared later, what sounds did you
actually hear?
 Would this be due to accumulated fluid posteriorly on the lungs while laying down???

32. What are bronchovesicular sounds? How do they sound? Where do you hear them?
 Normal breath sounds
 Center of the chest around bronchovesicular tree
 1st and 2nd intercostal space at sternal border; posteriorly at T4-- medial to scapula
 Heard on either side of the spine posteriorly
 Heard equally during inspiration and expiration

33. If someone has a pleural effusion and decreased fremitus what other signs and symptoms might you see?
(p. 202)
 “Accumulation of serous fluid in pleural space between visceral and parietal pleurae”
 Fever, tachypnea, tachycardia, trachea shifted to the other side, absent breath sounds on the affected side, chest
pain that is worse with cough and deep breaths, dyspnea, intercostal bulging, decreased chest wall movement

34. What is air in the subcutaneous tissue called? How does it feel? What does it sound like?
 Crepitus
o Feels like a crackling sensation under the fingers
 Indication of emphysema (COPD)
o trapped air in subcutaneous tissue of the lungs
 Wheezing and crackles heard
 Barrel chested
 Destruction of alveolar wall
 Diminished breath sounds
 Hyper-resonance percussion sounds

35. If someone is complaining of chest pain/nausea, what other signs & symptoms might they have?
 Stable & Unstable Angina/MI (only ones with chest pain and nausea)
o Dyspnea, diaphoresis, palpitations, weakness
o Pain is often described as pressure, burning, squeezing, crushing, full, or sharp
o Nitroglycerin tabs**

36. How can you tell if someone has venous insufficiency?

 “Venous valves damaged”
 History of venous thrombus (clot)
 Hair loss, lower leg edema, varicose veins, warm skin, redness

37. What is the Weber test?

 Vibration hearing test that assesses for conductive and sensorineural hearing loss
 Vibrating tuning fork placed on forehead, patient is asked which ear the sound is louder in
 The patient should hear the sound equally in both ears

38. What are the different types of hearing loss? How do you test them?
 Conductive- caused by the interference of air conduction in the middle ear (p. 176)-- can be due to blockage
o During a Weber test-- patient will report sound heard in affected ear
o During a Rinne test-- patient hears bone conduction longer than air conduction
 Sensorineural- caused by structural changes, disorders, of the inner ear, or problems with the auditory nerve; can be
associated with aging (presbycusis), trauma, virus, disease
o During a Weber test-- patient reports sound in unaffected ear
o During a Rinne test-- patient hears air conduction longer than bone conduction
 Mixed hearing loss- combination of conductive and sensorineural hearing loss
39. What is Nystagmus?
 Vision condition where the eyes make repetitive, uncontrolled movements
o resulting in reduced vision and depth perception
o can affect balance and coordination

40. How do you test accommodation?

 Reflex of the eye in response to focusing on a near object and then looking at a distant object
 Change in lens shape and pupil size
 Ask patient to look far away then focus on your finger

41. How do you test for eye movement?

 Movement associated with oculomotor (III), trochlear (IV), and abducens (VI) cranial nerves
 Ask patient to follow your finger while keeping their head still
 Six cardinal fields of vision

42. Nasal drainage that is purulent (pus), green, and yellow is a sign of what?
 Indication of infection

43. The patient reports that they vomited an hour ago, what other data do you need to collect?
 What did it look like?
 How much vomit was there?
 What did you eat?
 What medications do you take?

44. The patient reports a change in urination, what other data would you need to collect? (p. 253)
 Usual pattern of urination
 Any pain or burning felt during urination?
 How frequently or infrequently the patient is urinating?
 Any signs or symptoms associated with the change (fever, chills, back pain)?
o Back pain- kidneys
o Pelvic pain- bladder
 Color of the urine- can indicate hydration status/ dehydration
 Is there blood in the urine?
 Is there weight gain or weight loss?
 Is there SOB?
 Is there swelling in ankles?

45. What kinds of questions would you ask a patient with edema? (p. 217)
 Where is the swelling located?
o Arms or legs?
o Unilateral or bilateral?
 What makes the swelling go away?
 o Does elevation reduce the swelling?
o Does it disappear after you get sleep?
 Are there any signs and symptoms associated with the swelling?
o SOB?
o Weight gain?
o Warmth?
o Discoloration?
 Is the swelling associated with your period?
 Swelling differentiates between cardiac and respiratory problems with chest pain

46. What does an abdominal assessment look like on a healthy individual?

 Symmetry
 Tympany when percussed
 Surface characteristics should be smooth, with centrally located umbilicus.
 Striae, scars, faint vascular network.
 Contour: usually sunken; slight protrusion if overweight or obese.

47. What would you hear in the upper epigastric region of a healthy patient?
 Bowel sounds
 Hyperactive vs. Hypoactive
o If absent listen for a full minute
o Ask about last BM

48. When do you hear dull sounds?

 Over bone

49. When do you hear tympanic sounds?

 Over the abdomen

50. What are the risk factors for esophageal cancer? (p. 249)
 Age
 Gender
 History of GERD
 Barrett’s esophagus
 Smoking
 Alcohol use
 Obesity
 Diet (without fruits and vegetables)
 Workplace exposure (chemical fumes such as dry cleaners)
 Injury to the esophagus (accidently drinking lye-- corrosive agent)

51. What are the risk factors for colon cancer?

 Age (more common in older individuals)
 Family history
 Diabetes
 Pre-existing GI issues
 Tobacco use
 Alcohol use
 Teaching in regard to prevention: Smoking cessation
52. What is a Pustule? What does it look like?
 Small fluid filled bumps, white bumps around red skin
 Can be from acne
 Can be a result of hormonal imbalance

53. What are the different stages of a Pressure Ulcer? Be able to distinguish between them.
 Stage 1- redness, no break in skin
 Stage 2- partial thickness skin loss, shallow open wound with pink wound bed
 Stage 3- full thickness skin loss with damage to subcutaneous tissue
 Sage 4- full thickness skin loss with exposed muscle or bone
 Unstageable- eschar or slough may cover the entire wound bed

54. The patient reports that they have a Rash. What other data would you need to collect?
 When did it start
 Do they have any allergies
 What does it look like
 What does it feel like
 Does anyone around you have a similar rash
 Color, shape, texture, tenderness, bleeding, itching, swelling
 This question is a select all that apply and the answer is ALL OF THEM

55. Describe what the oral and nasal mucosa look like on a normal patient.
 Pink, moist
 No sores, ulcers

56. What is the normal ROM for the neck? (p. 287)
 Able to tilt chin to neck, tilt head backwards, tilt head side to side
 Touch chin to each shoulder
 Hyperextension 55 degrees
 Flexion 45 degrees
 Right and left lateral (ear to shoulder) 40 degrees
 Right and left rotation 70 degrees

57. What are the risk factors for Oral Cancer?

 Smoking
 Excessive alcohol use
 Changes in oral mucosa
 Lesions present
 Red/white patches
 Enlarged lymph nodes, bleeding, difficulty swallowing

58. What does a head (p. 145-146) and neck (p. 168) assessment look like on a healthy patient? - select all that apply
 Able to:
o shrug shoulders
o turn head and resist pressure when hand placed on patient’s face
o flex, extend, hyperextend, and move laterally
 Facial bones and features
o are proportioned and symmetric
o facial movement is smooth
 Skin
o smooth
o no lesions or edema
o on neck matches other skin areas
 Skull
o symmetric and intact, no tenderness
 Jaw
o moves smoothly and painlessly
 Neck is symmetric bilaterally

59. How do you assess triceps and bicep muscle strength? (p. 292)
 For triceps: ask patient to extend arm while you resist by pushing it to flex
 For biceps: have patient try to flex the arm while you try to extend their forearm
 Have patient pull and push on your arms
o Push forward against nurse’s hand to extend triceps
o Pull backward against nurse’s hand to flex bicep

60. How do you test ROM in the shoulder? (p. 291)

 Patient able to flex, extend, and hyperextend shoulder
 Able to perform adduction (arm swung across body), abduction, and circumduction

61. What does rheumatoid arthritis look like? What are the signs and symptoms?
 “Chronic autoimmune inflammatory disease of connective tissue”
 Fatigue, stiffness, muscle ache and weakness
 Pain, edema, fever
 Ulnar deviation, Swan Neck deformity, Boutonniere deformity
 Deterioration of cartilage
 Fibrotic and shortened ligaments and tendons

62. How do you assess for lumbar nerve compression?

 Does patient have any leg pain?
 Does patient have any neck pain?
 Have patient bend down and touch their toes
 Spurling’s test

63. How do you assess ROM in the hips? (p. 297)

 Patrick’s Test
 FAER test
 Abduction (leg away from center)/adduction (leg past center)
 Flexion, extension, hyperextension
o Flexion: knee to chest
o Extension/hyperextension: raise leg upward during prone position

64. How do you assess ROM in the ankle?

 Plantar flexion
 Dorsiflexion

65. What are the risk factors for Osteoporosis?

 “Loss of bone density and decreased bone strength”
 Due to aging, decline in estrogen, calcium deficit, lack of exercise
 Loss of height
 Brittle bones
 Kyphosis (convex curvature of the spine)
 White/Caucasian women

66. What are the signs and symptoms of a CVA? (Stroke)

 Numbness or weakness
o one sided (the side opposite of the side of brain affected)
 Trouble walking
 Dizziness
 Loss of balance
 Confusion
 Difficulty swallowing, speaking, or partial loss of vision
 One sided complete loss of function

67. How do you test the brachioradialis deep tendon reflex? (p. 328)
 Expected response is pronation of the forearm and flexion of the elbow
 Arm should be relaxed
o Holding arm slightly pronated
o use reflex hammer to strike brachioradialis deep tendon 1-2 inches above the wrist

68. A patient has recently had a seizure, what other assessment findings do you need?
 How often do they occur?
 When was the last seizure?
 What are they like?
 Do you become unconscious?
 Any warning signs before the seizure?
o Aura, pain, nausea
 Describe seizure movements
 Do you urinate or have a bowel movement during the seizure?
 Any factors associated with the seizure?
 Have the seizures interfered with your daily life activities?

69. What are the risk factors for a stroke?

 “Cerebral blood vessels become occluded by thrombus or embolus or when cerebral hemorrhage occurs”
 Hypertension
 Cerebral aneurysm
 Ischemia
 Aortic stenosis
 Atrial Fibrillation
 NCLEX Questions from New Material (Ch. 16, 17, 18, 19, 20, 21)

Chapter 16:
1. Which of the following is considered abnormal when conducting an examination on a 68-year-old woman?
(Serous nipple discharge)

2. A 58-year-old woman has found a small lump in her breast. Which data from her history are risk factors for
breast cancer?
She underwent radiation treatment for Hodgkin disease at age 17

3. What is the reason for palpating axillary lymph nodes during a clinical breast examination?
The lymph network in the breast primarily drains toward the axillary lymph nodes

4. A 19-year-old college student come to the student health center because she discovered a small, non-tender,
firm rubbery lump in her right breast. What is the most common cause of breast lumps in women her age?
Fibroadenoma

5. A 58-year-old man seeks treatment for recent breast enlargement. On examination, the nurse notes bilateral
enlargement of the breasts. Which question asked by the nurse is most appropriate based on this finding?
Gynecomastia
“What medications are you currently taking?”

Chapter 17:
1. Which finding does the nurse recognize as abnormal when examining a male patient?
Discharge from the penis when the glans is compressed

2. A 22-year-old white male comes to the emergency department with a concern about a mass in his testicle. In
addition to his age and race, which fact is a known risk factor for testicular cancer?
He had an undescended testicle at birth

3. Which data collected from the history of a 32-year-old female patient would be followed with a symptom
analysis?
Has pelvic pain and vaginal discharge

4. While taking the health history of a 23-year-old female patient, the nurse considers risk factors for STD.
Which data from the patient suggests a need for patient education?
She has been sexually involved with one man for the last 2 weeks, she uses spermicidal gel to prevent pregnancies.

5. A female patient has a herpes lesion on her vulva. While examining her, the nurse should take which
measure?
Wear examination gloves while in contact with the genitalia.

6. To inspect the glans penis of the uncircumcised male, the nurse retracts the foreskin. After inspection, she is
unable to replace the foreskin over the glans. The nurse recognizes that his situation could potentially lead to
which complication?
Tissue necrosis of the penis

8. The nurse recognizes which symptom as commonly associated with prostate enlargement?
 Weak urinary stream

10. A patient tells the nurse that her stools have bright red blood in them. The nurse suspects which problem?
Hemorrhoids

Chapter 18:
1. Which immunization does the nurse ask about when interviewing a 75-year-old patient?
Tetanus and Influenza

2. Which statement reflects an expected developmental task of a 40-year-old man?

“My wife and I have divided the chores with the children since we’re both working.”

3. Which finding is expected when assessing an 11-year-old child?

5 lb (2.3 kg) weight gain and beginning of a growth spurt

4. A nurse is assessing an infant who is able to pull up to a sitting position, turn from prone to side position,
laugh and babble, and show interest in her surroundings. These behaviors are consistent with an infant of
which age?
3 months old

5. A 15-year-old boy approaches the school nurse and describes how uncomfortable he is around the girls
because most of them are taller than he is. What is the nurse’s best response to this adolescent?
“The growth spurt during adolescence occurs in girls 18-24 months before it occurs in boys.”

Chapter 19:
1. Which finding on a 2-month-old baby is considered abnormal and required further follow up?
The anterior fontanelle is not palpable

2. A nurse is palpating the lymph nodes of an 18-month-old toddler and finds enlarged post-auricular and
occipital nodes. What is the significance of this finding?
This is a normal finding at this age

3. While examining the ear of an infant with an otoscope, the nurse pulls down on the ear for which reason?
Enhances visualization of the tympanic membrane by straightening the ear canal

4. What is an expected finding of the newborn’s vision that the nurse teaches the parents?
The newborn is nearsighted and cannot see items unless they are close

6. Which are expected findings of a newborn’s respiratory assessment?

Bronchovesicular breath sounds in the peripheral lung field
Abnormal finding in the elderly

7. Which finding of a preschooler during a cardiovascular system examination is abnormal?

Failure to gain weight because of fatigue while eating
indication of heart condition

8. What would be an abnormal finding for a 7-year-old African American boy?

Abdominal distention
 could indicate a hernia/mass

9. When examining the genitalia of a 3-year-old boy, which position is ideal?

Sitting position with knees spread and ankles crossed

10. On assessment of the neurologic status of a 4-month-old infant, the nurse notes which finding as
abnormal?
The infant steps in place when held upright with feet on a flat surface
infant should step forward

Chapter 20:

1. What does the nurse assess for during each prenatal visit?
Blood pressure

2. During an initial prenatal visit the nurse identifies which factor as consistent with a high-risk pregnancy?
Patient smokes 1 half pack of cigarettes a day

3. A patient with a missed menstrual period and nausea has which signs and symptoms of pregnancy?
Presumptive
Observed by the patient

4.What is the nurse assessing when measuring from the patient’s symphysis pubis to the top of the fundus?
Gestational age

5.Which is considered an abnormal finding during late pregnancy?

Watery vaginal discharge

Chapter 21:

1. During inspection of the mouth of a 72-year-old male patient the nurse notices a red lesion at the base of his
tongue. What additional information does the nurse obtain from the patient?
Alcohol and tobacco use

2.On inspection of the eye of an 82-year-old woman, the nurse notes which finding as normal?
Clear cornea with a gray-white ring around the limbus

3.The nurse notes which finding as abnormal during a thoracic assessment of an older adult?
Bronchovesicular breath sounds in the peripheral lung fields

4.In assessing the mood of an older adult patient, the nurse documents which finding as abnormal?
Depression that interferes with the ability to perform activities of daily living

5.Which would be an abnormal finding during an abdominal examination of an older adult?

Report of incontinence when sneezing or coughing

6.Which finding is a normal (expected age-related) change for an 80-years-old woman?

Loss of height