exam two basic nursing skill test (copy)

What should you obtain when getting health history of ears?

Use of hearing aids, trouble hearing lose your balance ever hear a ringing

What is the cornea of the eye?

Transparent layer that covers Iris and pupil

Conjunctiva of eye

Mucus membrane that lines the eyeball

Outer layer of the eyeball

Scalera

Colored portion in the center of the eye

Iris

Correct order to examine conjunctiva

Gloves on place thumbs below lower eyelids and stretched client to look up pull skin down and inspect the color

What indicates a thyroid disorder

Lump on interior portion of neck

What indicates vitamin B12 deficiency?

Beefy, red tongue

Client who has liver disease will likely also have

Yellow Scalera

Bell’s palsy causes

Asymmetry of facial features

Hirsitusim causes

Facial hair on female client

If a client has candidiasis, what should you expect to find?

White patches on tongue aka thrush

Skull fracture can be indicated by

Watery clear drainage of ear

If client has difficulty reading during assessment, where should the nurse documents?

Review of system section in EHR

A client had suspected stroke. What action should the nurse take?

Take vitals, make NPO assess orientation, assess muscle strength

What indicates respiratory distress or decreased oxygen?

Clubbing of the fingers

What is an expected variation of respiratory system?

thoracic breathing

Normal signs of respiratory system

Pinkish hue on cheek thoracic breathing

Where would you hear bronchi breath sounds

To the right and left of the trachea and larynx Larry on the anterior side of the chest

what is your priority if a patient has difficulty breathing

Elevate the head of the bed

what does rhonchi sound like

low pitch snoring type sound hard during exhale

what does strider sound like

High pitch growing sound in the neck area (larynx trachea

what indicate client is experiencing respiratory difficulty

Sitting in a tripod position using pursed lips breathing client appears confused

What describes a plural friction?

Horse grading tone, part on inspiration and expiration snoring sound pain with breathing

Cheyenne stokes breathing

Periods of deep breathing, alternating with apnea

Where can you access darker skin client for adequate oxygenation

Oral mucosa and nailbeds

If a patient has COPD and gets the flu vaccine

Patient should make effort to receive flu vaccine every year

What is expected for a client with hyperventilation?

Numbness and tingling of extremities, lightheadedness, chest pain. Heart palpitations .

Where is the point of maximum impulse?

Mitral and apical pulse point fifth intercostal space for movement.

When conducting a cardiovascular assessment, what should you assess

Oscillate apical pulse? Ask client if they have shortness of breath check client skin tone inspect for presence of edema

Normal blood pressure range

Systolic less than 120 and diastolic 60 to 80

elevated blood pressure range

systolic 120-129 and diastolic less than 80

hypertension stage one

Systolic 130-139 or diastolic 80-89

hypertension stage two

Systolic greater than 140 or diastolic greater than 90

hypertensive crisis

systolic greater than 180 and or diastolic greater than 120

hypotension blood pressure range

systolic less than 90 diastolic less than 60

cataplexy

Muscle weakness/loss and muscle tone due to laughter

When does streaming occur

rapid eye movement stage four of the sleep cycle

causes of obstructive sleep apnea

Obesity, active tongue enlarged tonsils

What happens to our memory during sleep?

Compartmentalization Thomas transfer his information to cerebral cortex, transferring it from a short term to long-term memory

What happens during REM sleep?

Thalamus transmit images sounds and sensation which influence contacts of dreams

What happens physiology during REM sleep cycle?

Heart rate, blood pressure, respirations increase muscle paralysis, or Antonia active brain unstable vital signs

What is hypocrites

Promotes wakefulness and alertness — keep you awake and prevent sudden sleep

melatonin

hormone that helps you sleep

narcolepsy one

Periods of REM during wakefulness experiences loss of muscle tone due to cataplexy lack hypocriten

narcolepsy two

Periods of REM during daytime chronic sleep does not experience, cataplexy or loss, muscle tone lack hypocretin

hypersomnia

Daytime fatigue does not improve with rest

insomnia

Inability to fall asleep or stay asleep. Do not have trouble staying awake.

iron deficiency can cause

fatigue, color, spoon shaped nails anemia

Vitamin A deficiency can cause

night blindness damaged skin integrity

vitamin C deficiency can cause

Bleeding gums

Easy bruising,Petechiae

Impaired wound healing

What are biologically based practice therapies?

Herbs, vitamins, minerals, probiotics

What are whole medical systems?

Homeopathy, naturopathy, traditional Chinese medicine, a ayruveda

Difference between complementary and integrative health approaches

Complementary is combining approaches casually on the client side, Intergrative as the structured combination on the hospital side

what improves iron absorption

Vitamin C, like orange juice