N114 - Final Exam Review

Key Terms
Paroxysmal nocturnal dyspnea
Sudden awakening of the patient, after 1 or 2 hours of sleep, with the sensation of
breathlessness, difficulty, or uncomfortable breathing, usually relieved in the upright
position.
Intermittent claudication
An aching, cramping, tired, and sometimes burning pain in the legs that comes and goes
it typically occurs with walking and goes away with rest due to poor circulation of
blood in the arteries of the legs. In very severe claudication the pain is also felt at rest.
Intermittent claudication may occur in one or both legs and often continues to worsen
over time.
Care variance
Any event or circumstance not consistent with the standard routine operations of the
hospital and its staff or the routine care of a patient/visitor.
Key Abbreviations
SBAR Situation, Background, Assessment, Recommendation
DAR Data, Action, Response
SOAP Subjective, Objective, Analysis, Plan
PERRLA Pupils Equal, Round, Reactive, to Light, and Accommodation
TMJ Temperomandibular joint - Should not click or have pain with jaw movement
1. Types of assessments
a. Comprehensive
i. A detailed history and physical examination performed at the onset of care
in a primary care setting or on admission to a hospital or long care facility.
b. Focused
i. A history and examination that are limited to a specific problem or
complaint (e.g. a sprained ankle). This type of assessment is most
commonly used in a walk-in clinic or emergency department.
c. Episodic/Follow-up
i. Usually done when a patient is following up with a health care provider
for a previously identified problem.
d. Screening
i. A short examination focused on disease detection (as part of a
comprehensive examination, or at a health fair). Ex: BP, glucose,
cholesterol, or colorectal screenings.
2. Standards for giving report
a. Specific, organized, to the point
b. Measureable
c. Continuity of care
3. Critical thinking characteristics
a. Intuitive, logical, or both
b. cognitive, technical, interpersonal, ethical/legal, creative

4.

5.

6.

7.

8.

i. Guided by standards, policies and procedures, ethics, laws

ii. Based on principles of nursing process, problem solving, scientific method
iii. Carefully identifies key problems, issues, risks, including patients,
families, and major care providers
iv. Driven by patient, family, and community needs, as well as nurses needs
to give competent, efficient care
v. Strategies that make most of human potential and compensate for
problems created by human nature
vi. Constantly re-evaluating, self-correcting, and striving to improve
Steps of the nursing process
a. Assessment
b. Diagnosis
c. Expected/Outcome identification
d. Planning
e. Implementation
f. Evaluation
Ethics in nursing
a. Accountability
b. Reporting incompetent, unethical, or illegal practices
c. ANA Code of ETHICS guidelines and protocols from State Nurse Practice Acts
and Regulations, the Scope of Practice, Professional Standards of Nursing
Practice, professional code of ethics, Federal and State health regulations,
pharmacy laws, OSHA standards and regulations, medical records and
communicable disease laws, environmental laws, CDC and Prevention guidelines,
antidiscrimination laws, service facility regulations, Clinical Improvement Act,
Joint Commission regulations.
Cultural diversity
a. Includes differences in gender, age, culture, race, ethnicity, religion, sexual
orientation, physical or mental disabilities, and social and economic status.
b. Skin color, language, health practices, beliefs, religious practices, and values.
Functional health patterns
a. Health Perception/Health Management
b. Nutritional/Metabolic
c. Elimination
d. Activity/Exercise
e. Sleep-Rest Pattern
f. Cognitive-Perceptual Pattern
g. Self-Perception/Self-Concept Pattern
h. Sexuality/Reproductive Pattern
i. Role/Relationship Pattern
j. Coping/Stress Tolerance Pattern
k. Value/Belief Pattern
Maslows hierarchy (p. 229 Taylor)
a. Physiologic (Survival) Needs:
i. Food, fluids, oxygen, elimination, warmth, physical comfort
b. Safety and Security Needs:

i. Things necessary for physical safety (cane) and psychological security

(childs favorite toy)
c. Love and Belonging Needs:
i. Family and Significant Others
d. Self-Esteem Needs:
i. Things that make people feel good about themselves and confident in their
abilities (being well groomed, having accomplishments recognized)
e. Self-actualization Needs:
i. Need to grow, change, and accomplish goals
9. Methods of prioritizing
a. Ask yourself the following questions
i. When problems need to be addressed (immediate or later)
ii. Which problems do you need to solve and which can be delegated
iii. Which problems can be solved with a standard plan of care
iv. Which problems aren't covered by standard plans of care but must be
addressed for a safe stay and timely discharge?
10. Electronic documentation
a. Improves standards of care through improvement of diagnosing and planning
interventions. Research shows EHRs result in significantly less medical errors.
11. Documentation styles and standards
a. DAR - "Focus charting," emphasis on patient and patient's priorities
b. SOAP - Organize entries in problem-oriented medical records.
c. Narrative - Address routine care, normal findings, and patient problems
d. SBAR - Provides framework for communication between health care workers
12. Nursing care planning
a. Diagnosis - NANDA diagnoses, not medical diagnoses.
i. Actual - Current problem
ii. Risk - More likely to develop problem than others
iii. Wellness - Ready for enhanced learning and healthy lifestyles
iv. Collaborative - Labeled "PC: (whatever the problem is)." Collaborative
problems involve members of the health care profession other than nurses.
These are not NANDA diagnoses.
b. Outcome/planning - Planning of nursing care interventions. Plans must be
specific, measurable, attainable, realistic, and timely (SMART).
c. Intervention - Organizes resources (people, supplies, environment, etc) and
implement planned interventions.
d. Evaluation - Based on patient response to interventions, decide to terminate,
modify, or continue plan of care.
13. Scope of practice, delegation
a. RNs cannot delegate other RNs towards tasks - This is a trading of responsibility,
not delegation. They can, however, delegate to LPNs and STNAs. Delegation
cannot go up for to equals. When a nurse makes a delegation, it must be in the
scope of practice for that individual. This delegation also remains the RN's
responsibility, regardless of if they are doing the task or not.

14. Critical pathways

a. Abbreviated summary of key information taken from the more detailed case
management plan. Includes expected outcomes, interventions, and
sequence/timing of those interventions.
15. Quality improvement
a. Primarily done through evaluation. Can be evaluation from superiors, equals, or
subordinates. Peer review is key. Done in order to improve quality of care.
16. Communication techniques
a. Charting - Needs to be accurate and concise.
b. Oral report - Useful because it's clear and receiver can directly ask for
clarification. A disadvantage is that there is no record of such reports.
c. Electronic - Offers a record of communication and is instant. However, nonverbal
communication is lacking and privacy concerns are often an issue.
17. Positions for examination
a. Sitting
b. Supine
c. Prone
d. Dorsal recumbent (on back, knees bent)
e. Lateral recumbent (on side, knees bent)
f. Sims (on chest, flexion of hip and 1 bent knee)
g. Lithotomy (supine, with stirrups)
h. Knee-chest
18. Pain assessment
a. OLD CARTS onset, location, duration, character, aggravating/alleviating,
related S/Sx, treatment, severity
b. Acute recent onset, less than 6 months, may cause physiologic signs.
c. Persistent (chronic) intermittent or continuous, more than 6 months. Not those
of physiologic stress because people adapt to the pain, resulting in irritability,
depression, withdrawal, insomnia.
d. Nociceptive arises from stimulation of somatic structures (bone, joint, muscle,
skin, connective tissue, or stimulation of visceral organ i.e. gastrointestinal tract or
pancreas). Results from activation of essentially normal neural systems.
e. Neuropathic occurs from abnormal processing of sensory input by the central
or peripheral nervous systems
f. Referred pain felt in location away from the area of tissue injury or disease
g. Phantom pain pain that a person feels in an amputated extremity after the
residual limb has healed.
19. Problem based history of nutritional assessment
a. Weight loss how much in last 6 months, what is your normal weight,
sudden/gradual, desired/undesired, advanced age
i. Bruising, headaches, fatigue, constipation, hair loss, cracks in corners of
mouth
b. Weight gain how much in the last 6 months, what is your normal weight,
sudden/gradual, intentional/unintentional, medical conditions, certain medications
c. Difficulty chewing or swallowing time frame, which types of foods causes
most problems/without difficulty, weight changed since onset of problem

d. Loss of appetite or nausea onset, constant or intermittent, medications,

pregnancy, certain chronic illnesses, depression, which are most offensive or
intolerable, which are without difficulty, change of weight since onset
20. Problem based history of respiratory assessment (OLD CARTS)
a. Cough
i. Acute viral infections, allergic rhinitis, acute asthma, acute bacterial
sinusitis, environmental irritants
ii. Chronic postnasal drip, GERD, asthma, bronchitis, BP drugs, ACE
inhibitors.
iii. Viral pneumonia dry cough
iv. Bacterial pneumonia productive cough
v. Sputum
1. In morning- common with bronchitis
2. w/change in position suggests lung abscess and bronchiectasis
3. white or clear colds, viral infections or bronchitis
4. black smoke or coal dust inhalation
5. rust tuberculosis or pneumococcal pneumonia
6. Hemoptysis- containing blood
7. Pink/frothy associated w/ pulmonary edema
8. Thick commonly associated w/ cystic fibrosis
9. Foul-smelling bacterial pneumonia, lung abscess, bronchiectasis
b. Shortness of breath
i. Orthopnea difficulty breathing lying down
ii. Paroxysmal nocturnal dyspnea
c. Chest pain with breathing
i. Pneumonia
ii. Heart disease
iii. Pleuretic chest pain sharp, abrupt pain associated with deep breathing
may be an indication of pleural lining irritation
iv. Shallow breathing (i.e. due to injury) may lead to respiratory congestion
21. Classifications of blood pressure Systolic
Diastolic
a. Normal
<120
and
<80
b. Pre-hypertension
120-139
or
80-89
c. Stage 1 hypertension 140-159
or
90-99
d. Stage 2 hypertension 160
or
100
22. Equipment used during examination
a. Visual acuity charts
i. Snellen Chart - Viewed from a distance, 10 or 20 feet
ii. Rosenbaum/Jaeger Chart - Viewed from up close, 14 inches
23. Vital sign techniques and interpretation
a. I'm pretty sure we all know vital signs really, really well at this point.
24. Abdominal assessment
a. Pg 272 of Wilson, 5th edition

25. Types of fractures

a. Open - Any fracture that has led to a break in the skin, exposing insides.
b. Closed - Fracture that does not break the skin.
c. Spontaneous - Fracture due to weakening of the bone (osteoporosis, etc)
26. Staging of wounds
a. Stage 1 wounds do not have any visible skin cuts, can be remarkably different
from surrounding area (temp, firmness, color, painful, itchy)
b. Stage 2 the topmost layers of skin is severed. May be some drainage
c. Stage 3 wounds are deeper than stage 2, typically go down to fat layer, do not
extend further. May be dead tissue and drainage.
d. Stage 4 wounds are very serious. Wounds are characterized by going as far
down as to the bone and muscle. Dead tissue and drainage are almost present.
27. Gout: risk and anatomy & physiology
a. Hereditary. Increase in serum uric acid caused by increased production or
decreased excretion of uric acid and urate salts. Thought to be caused by lack of
enzyme needed to completely metabolize purines for renal excretion. (high in
purines: poultry, liver, kidney, legumes). Commonly accumulates in joints (great
toe, wrists, hands, ankles, knees). Painful, limited ROM, tophi are sign of gout
(large irregularly shaped deposits in SQ tissue/joints. Kidney stones from uric
acid crystals can cause flank pain and costovertebral angle tenderness.
28. Skin: assessment, wounds, viral, bacterial, & fungal conditions, hair conditions
a. Viral
i. Warts (Verruca) - Benign communicable lesion. Vary greatly.
ii. Herpes Simplex - Chronic condition, transmitted through contact. Lies
dormant until outbreaks, which lead to stinging and itching sensations.
iii. Herpes Varicella (chickenpox) - Highly contagious, very itchy.
iv. Herpes Zoster (Shingles) - Dormant varicella. Painful, usually unilateral.
b. Fungal
i. Tinea infections (ringworm, jock itch, athletes foot)
ii. Candidiasis normally found on skin, mucous membranes, GI tract,
vagina. A scaling red rash with sharply demarcated borders, generally a
large patch but may have some loose scales.
c. Bacterial
i. Cellulitis Acute streptococcal or staphylococcal infection of the skin and
SQ tissue. Warm to touch, tender.
ii. Impetigo Highly contagious bacterial infection caused by group A
streptococcus, by contact. Most commonly on face.
iii. Folliculitis - Inflammation of hair follicles.
iv. Furuncle or abscess Boil, a localized bacterial lesion caused by a
staphylococcal pathogen. Appears as a pustule.

29. You will be tested on the cranial nerves and assessments Pg 341
a.
Number/Name
Type
Memory Word
i. I Olfactory
Some
On
ii. II Optic
Say
Old
iii. III Oculomotor
Marry
Olympus
iv. IV Trochlear
Money
Towering
v. V Trigeminal
But
Top
vi. VI Abducens
My
A
vii. VII Facial
Brother
Fin
viii. VIII Acoustic
Says (its)
And
ix. IX Glossopharyngeal
Bad
German
x. X Vagus
Business (to) Viewed
xi. XI Spinal accessory
Marry
Some
xii. XII Hypoglossal
Money
Hops
30. Scoring for deep tendon reflexes
a. 0 = No response | 1+ = Sluggish, diminished | 2+ Normal
3+ = Slightly hyperactive, but not always pathogenic
4+ = Brisk, hyperactive. Associated with disease.
31. Documenting altered level of consciousness
a. Glasgow Coma Scale: Eye opening (1-4), Motor resp. (1-6), Verbal resp. (1-5)
b. Awake and alert - Standard
c. Lethargic - Easy to arouse, though likely to return to sleep quickly
d. Stuporous - Requires painful stimuli to arouse, but only to withdraw from pain
e. Comatose - Do not respond to any stimuli
32. Disorders of the CNS
a. Headaches
i. Migraine - Throbbing, unilateral, pain. Can lead to sensitivity to light and
sounds, depression, restlessness, nausea, and vomitting.
ii. Cluster - Very painful. Burning, stabbing pain. Can last up to an hour, but
often recurs for several weeks (hence "cluster")
iii. Tension - Most common. Bilateral and diffuse pain, usually described as
pressure squeezing head.
b. Dizziness - Defined in #33
c. Seizures
d. Loss of consciousness
e. Changes in movement
f. Changes in sensation
g. Difficulty swallowing (dysphagia)
h. Difficulty communicating (dysphagia/aphasia)
33. Eye examination
a. Vision acuity - Sharpness of vision
b. Peripheral
c. Conjunctiva
d. Cornea
e. Sclera

f. Lids, lashes, brows

g. Iris
h. Pupil
34. Common problems of the musculoskeletal system
a. Osteoporosis - Serious loss of bone density. Occurs without signs or symptoms
until it's greatly advanced. Has a relationship with lack of calcium and lack of
weight-bearing exercise.
b. Rheumatoid arthritis - Chronic autoimmune inflammatory disease. Onset is
gradual, and most of the time is bilateral. Often accompanied by low-grade fever,
edema, and fatigue.
c. Gout - Increase of serum uric acid. Erythema and edema of joints, can make it
extremely painful to move.
d. Bursitis - Inflammation of connective tissue surrounding a joint. Painful and
limited RoM, tender on palpation.
e. Osteoarthritis - Caused by degenerative changes in articular cartilage. Affects
mostly weight-bearing bones. Manifests as a chronic, aching, pain.
f. Herniated nucleus pulposus - Also called a herniated or slipped disc. Occurs when
cartilage between vertebral discs is displaced. Frequently from improper
technique when doing heavy-lifting. Symptoms vary based on which disc slipped.
g. Scoliosis - S-shaped spine. Can be congenital, result from neuromuscular disease,
or from traumatic injury. Depending on severity, may compromise function of
heart, lungs, and pelvic organs.
h. Carpal tunnel syndrome - Median nerve is compressed. Reports of numbness,
pain, and paresthesia when doing diagnostic tests (Phalen's or Tinel's).
35. Dizziness definitions, types
a. Presyncope feeling of faintness and impending loss of consciousness often a
cardiovascular symptom
b. Disequilibrium feeling of falling often a locomotor problem
c. Vertigo sensation of movement, usually rotational motion such as whirling or
spinning. Cardinal symptom of vestibule dysfunction.
d. Light-headedness vague description of dizziness that does not fit any of the
other classifications usually idiopathic or psychogenic
36. Tonsil enlargement
a. +1 visible
b. +2 halfway between tonsillar pillars and uvula
c. +3 nearly touching the uvula
d. +4 touching one another
37. Guaiac testing
a. Testing for blood in feces. Avoid foods/medications that could corrupt results.
38. Infection control principles
a. Hand hygiene is important, wear protective equipment as directed...not exactly
sure what to write for this one, seems like mostly basic knowledge.
39. Factors affecting BP measurement
a. Age, race, gender, medication, heredity, personal habits, emotions, pain, weight

40. Assessing dietary intake

a. 24-hr recall - Recalls what has been eaten in the past 24 hours. Quick and easy,
but not likely to be reflective of a typical daily intake.
b. Typical food intake - Describes what types of food patient usually eats.
c. Food diary - Records food intake for specified amount of time. Requires a followup appointment and analysis is time consuming.
d. Food frequency questionnaires - Indicates frequency of intake of certain foods.
Doesn't assess intake of foods, usually only lists major nutrients.
e. Comprehensive diet history - In-depth interview providing detailed information
regarding food intake. Time consuming and requires a trained professional.
41. Laboratory tests nutritional assessments (lipid profile), blood sugar, Hgb/Hct
a. Lipid profile
i. Cholesterol <200mg/dl
ii. Triglycerides
1. Male 40-160
2. Female 35-135
iii. HDL (want high)
1. Male 45
2. Female 55
iv. LDL (lousy) 60-180
b. Blood sugar 70 105 mg/dl
c. Hgb
i. Male 14-18g/dl
ii. Female 12-16g/dl
d. Hct (%)
i. Male 4252%
ii. Female 3747%; 33% pregnancy
e. Albumin
i. Serum 3.5g/dl (3-4 weeks)
ii. Prealbumin 15-36mg/dl (2-3 days)
42. Medication administration techniques (eye, ear, nose)
a. Eye
i. lower lid pulled down, administer eyedrops on the lower conjunctival sac.
Close eye gently, apply gently pressure with gloved finger over the inner
canthus to prevent the eyedrops from flowing into tear duct.
ii. About of ointment is squeezed from tube along exposed conjunctival
sac, from inner canthus to outer canthus. Patient to close eye gently, move
eye around to spread ointment, warmth helps to liquefy ointment.
b. Ear straighten auditory canal (pull up and back on pinna on adults, down and
back on infants or child under 3, or straight back for school-aged child). Drops to
fall on side of the canal, uncomfortable if directly onto tympanic membrane.
Release pinna, have patient maintain position, gentle pressure on tragus a few
times. Wait 5 minutes before instilling drops into other ear.

c. Nose blow nose. Sit up with head tilted well back. Enough solution in dropper
for both nares. Hold up tip of nose, place dropper just inside naris, about 1/3
without touching naris. Remain in position for a few minutes to prevent solution
from escaping.
43. BMI Values
a. BMI
i. Normal 18.5 - 24.9
ii. Overweight 25 29.9
iii. Obesity class I 30 - 34.9
iv. Obesity class II 35 39.9
v. Obesity class III 40