1
Remain alert for generalized edema, plus
hypertension, which suggests preeclampsia,
a dangerous obstretric condition
Expect diffuse bilateral pitting edema in lower extremities,
especially at the end of the day & into 3rd trimester
Nearly 80% of pregnant women have some peripheral edema
because of increased water retention
Varicose veins in legs also common in 3rd trimester
NR304 EXAM 1 LATEST 2023 ACTUAL EXAM
COMPLETE EXAM QUESTIONS AND CORRECT
DETAILED ANSWERS (VERIFIED ANSWERS)
|ALREADY GRADED A+
- Signs of DVT (clinical manifestations) – 2 questions
○ Unilateral swelling of the affected leg
○ Tendernessto severe pain
○ Possibly warmth & redness (accompanying inflammation)
○ Possibly superficial venous dilation - Effects of smoking
○ Bilateral cool feet
○ Strongest risk for peripheral vascular disease
○ Risk for arterial ulcers
○ Risk for atherosclerosis - Assessing peripheral blood flow
○ Modified Allen Test → → →
○ Doppler
○ Capillary refill - Peripheral vascular system assessment for different age groups
○ Infants & Children (normal vs. abnormal findings)
Transient acrocyanosis & skin mottling at birth
Pulse force should be normal & symmetric
Force should be same in upper & lower extremities
Weak pulses occur with vasoconstriction of
diminished CO
Full, bounding pulses occur with patent ductus
arteriosus from the large left-to-right shunt
Diminished or absent femoral pulses but normal
upper-extremity pulses suggest coarctation of aorta
Palpable lymph nodes occur often (healthy)
They are small, firm (shotty), mobile, nontender
May be sequelae of past infections
Vaccinations can produce local lymphadenopathy
Note characteristics of palpable nodes
(local/generalized)
Enlarged, warm, tender nodes indicate current
infection
Look for source of infection
○ Pregnanacy (normal vs. abnormal findings)
○ Older adults (normal findings)
■ The dorsalis pedis & posterior tibial pulses may become more difficult to find
■ Trophic changes associated with arterial insufficiency
2
● Thin, shiny skin
● Thick-ridged nails
● Loss of hair on legs
- Why/how would you use a Doppler?
○ Why?
■ Doppler flow studies can ensure collateral flow that is quantifiable
3
■ To detect a weak peripheral pulse
■ To monitor BP in infants or children
■ To measure a low BP or BP in a lower extremity
○ How?
■ Probe magnifies sounds from the heart & blood vessels
■ Position the person supine, with legs externally rotated so you can reach medial ankles easily
■ Place a drop of coupling gel on the end of the handheld transducer
■ Place transducer over a pulse site at about a 90-degree angle
■ Apply very light pressure & located the pulse site by the swishing, whooshing sound
- Signs of PAD
○ Ankle-Brachial Index (ABI) of 0.90 or less
■ 0.90 – 0.71 → mild PAD
■ 0.70 – 0.41 → moderate PAD
■ 0.40 – 0.30 → severe PAD
○ Pain Profiles
■ Location
● Deep muscle pain (usually in calf, but may be lower leg or dorsum of foot)
■ Character
● Intermittent claudication (feels like <cramp,= <numbness & tingling,= or <feeling of cold=)
■ Onset & duration
● Chronic pain, onset gradual after exertion
■ Aggravating factors
● Activity (walking, stairs)
○ <Claudication distance= → specific number of blocks, stairs it takes to produce pain
● Elevation (rest pain indicates severe involvement)
■ Relieving factors
● Rest (usually within 2 minutes)
● Dangling (severe involvement)
■ Associated symptoms
● Low ankle-brachial index
● Cool, pale skin
● Diminished pulses, pallor on elevation
○ Signs
■ Arteriosclerosis (peripheral blood vessels more rigid)
■ Atherosclerosis (deposition of fatty plaques on intima of arteries)
■ Poor wound healing
■ Intermittent claudication (leg cramping when walking)
■ Ischemic rest pain
■ Coolness
■ Weak, <thready= pulse (1+)
lOMoAR cPSD|19500986
NR304 FINAL EXAM 2023 ACTUAL EXAM COMPLETE
EXAM QUESTIONS AND CORRECT DETAILED
ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED
A+
WITH ANSWER KEY
- Which assessment by the nurse most likely indicates that a patient is having difficulty
breathing?
a. 18 breaths per minute and inhaled through the mouth
b. 20 breathes per minute and shallow in character
c. 16 breaths per minute and deep in character
d. 28 breaths per minute and noisy - Which should a nurse always do when taking a rectal temperature?
a. Allow self-insertion of the thermometer.
b. Position the patient on the left side.
c. Use an electronic thermometer.
d. Lubricate the thermometer. - A nurse is assessing a patient’s ideal body weight. Which significant factor
should be takin into consideration when performing this assessment?
a. Daily intake
b. Body height
c. Clothing size
d. Food preferences - A nurse asks a patient’s wife specific questions about the patient’s health status
before admission. When collecting this information, the nurse is seeking
information from a:
a. Primary source
b. Tertiary sources
lOMoAR cPSD|19500986
c. Subjective source
d. Secondary source
lOMoAR cPSD|19500986
- A nurse is preforming a physical assessment of a newly admitted patient. Which
patient statement communicates subjective data?
a. “I have sores between my toes.”
b. “I dye my hair but it isreally gray.”
c. “My joints hurt when I get up in the morning.”
d. “My left leg drags on the floor when I am walking.”
lOMoAR cPSD|19500986
- A nurse takes a patient’s blood pressure and records a diastolic pressure of 120 mm
Hg. Which should the nurse do first?
a. Notify the primary health-care provider.
b. Retake the blood pressure.
c. Notify the nurse in charge.
d. Take the other vitalsigns. - A patient had a stroke that resulted in paralysis of the right side. When clustering
data, the nurse grouped the following together: drooling of saliva and slurred
speech. Which information is most significant to include with this clustered data?
a. Receptive aphasia
b. Inability to ambulate
c. Difficulty swallowing
d. Incontinence of bowel movements - A patient who experienced a stroke has left-sided hemiparesis and is incontinent of
urine. Which is an appropriately worded nursing diagnosis for this patient?
a. The patient has a need to maintain skin integrity.
b. The patient has a stroked evidenced by hemiparesis and incontinence.
c. The patient will be clean and dry and will receive range-of-motion exercises every
four hours.
d. The patient is at risk for impaired skin integrity related to left-sided
hemiparesis and incontinence. - A nurse uses the interviewing process of clarification when interviewing a patient.
Which is the nurse doing when this communication technique is used?
a. Paraphrasing the patient’s message
b. Restating what the patient has said
c. Reviewing the patient’s communication
d. Verifying what is implied by the patient
NR304 EXAM 2 ACTUAL EXAM 2023-2024 COMPLETE EXAM TEST
BANK 200 QUESTIONS AND CORRECT DETAILED ANSWERS
(VERIFIED ANSWERS) |ALREADY GRADED A+
what are some modifiable risk factors for osteoporososis
smoking, increasing calcium and vitamin D intake, gaining some weight, hormone
therapy (for things like estrogen in postmenopausal women)
what are the two types of ischemic stroke?
thrombotic and embolic
of thrombotic and embolic strokes, which of the two is a result of atheroscleorsis
thrombotic
of thrombotic and embolic strokes, which of the two is a stationary blood clot
thrombotic
of thrombotic and embolic strokes, which of the two occurs as a result of heart
conditions such as atrial fibrilation?
embolic
what are the symptoms of a hemorrhagic stroke
“worst headache of their life”, nausea and vomiting, LOC, and focal seizures. This
type of stroke is deadly and rare and is because of an aneurysm or blood vessel that
ruptures, only about 13% of all strokes ????
what are some reasons that a person would have a stroke?
untreated hypertension, cigarette smoking, lack of exercise, heart disorders, high
BMI, high blood glucose, high total cholesterol, environmental factors such as
pollution
know FAST
F- facial drooping
A- arm weakness
S- smile or speech difficulty
T- time to call 911
what functions does a stroke effect?
cranial nerves (changes in hearing, chewing, swallowing, or vision)
motor nerves (changes in strength and balance)
sensory nerves (changes in ability to touch or feel sensation)
reflexes (poor reaction. or NO reaction to stimuli)
know cranial nerves
I- (olfactory) 1- smell, hardly ever test, but make them sniff something like a
lemon or alcohol pad
II – (Optic) 2- use Snellen chart
III – (Oculomotor) 3- raise eyebrows up and close lids
IV – (Trochlear) 4- look inward and downward
V – (Trigeminal) 5- (tri or three parts of face- taste, sensation, movement)
VI – (Abducens) 6- ABDUCT your eyes to the sides
VII – (Facial) 7- whole FACE- taste, sensation, smile
VIII – (Auditory or Vestibulocochlear) 8- COCHLEAR- ear
IX – (Glossopharengeal) 9- you put lip GLOSS on your mouth ???? (tongue and
pharynx, so taste and swallow) uvula should be midline
X – (Vagus) 10 – VAGabond or “wandering nerve”- innervates organs from ALL
OVER the body
XI – (Spinal Accessory) 11- we SHRUG off men that are no good cause you were
just an ACCESSORY anyway ♀️ (I don’t feel that way, its just easy to remember
lol)
XII – ( Hypoglossal) 12- GLOSS- so mouth/tongue
what is a normal test for the Glasgow coma scale?
15
what reflects a coma on the Glasgow coma scale?
7 or below
which connects bone to bone, a ligament or a tendon?
ligament
know the four lobes of brain
frontal- emotions, personality, behaviors
parietal- primary center for sensation
TEMPOral- primary center for hearing, taste, or smell (you can hear a TEMPO)
occipital- visual/sight
Wernicke’s area
in the temporal lobe
comprehension of language
(to me, Wernicke’s is the longer and crazier sounding word so I just think, “that
sounds like a crazy word I can’t comprehend it”
broca’s area
in the frontal lobe
speech production
(I remember this by thinking, “this BRO is so drunk he CAn’t even talk properly
(BRO-CA)” this makes sense in two ways because the frontal lobe is personality
AND speaking. Drunk bro can’t speak right.