NUR209/ NUR 209 Exam 1 Version 2(New 2026/ 2027 Update) Medical Surgical Nursing II Review | Q&A

Exam

1 …..DLDD\\\\\\\ NUR209/ NUR 209 Exam 1 Version 2(New 2026/ 2027 Update) Medical Surgical Nursing II Review | Questions and Answers| 100% Correct| A Grad ... e – Fortis Q. A process that evaluates or appraises the needs, preferences, and abilities of a patient. Answer Nursing assessment Q. The most important part of the nursing process. Answer assessment Q. Information that we get from the patient and the family perspective. Answer historical assessment Q. Includes asking more questions and using a hands on approach, biological and physiologial aspects using our senses. Answer physical assessment Q. Finding out about the drugs the patient is taking. Answer pharmacological assessment 2 Q. A mental status exam, telling us if they are oriented and able to cope with stress and problems. Answer psychological assessment Q. Determining the patients family structure, roles of the pt. in the family, and their S.O. Answer social assessment Q. Includes the assessment of intimate partner violence, child abuse, and elder abuse Answer domestic violence assessment Q. 2 types of intimate partner violence Answer physical partner violence & psychological emotional abuse Q. Failure to provide for a child's basic needs Answer neglect Q. Physical injury Answer physical abuse Q. Includes fondling a child's genitals, incest, penetration, rape, sodomy, indecent exposure, and commercial exploitation through prostitution or the production of pornographic materials. Answer sexual abuse 3 Q. Any pattern of behavior that harms a child's emotional development or sense of self-worth. Answer emotional abuse Q. Intentional actions that cause harm or create serious risk of harm to a vulnerable elder by a caregiver or person who stands in a trust relationship to the elder Answer elder abuse Q. The most common form of intimate partner violence, being struck with an object. Answer blunt force injury Q. When the blunt injuries cause the skin to tear, the wound is called___ Answer laceration Q. When a sharp instrument slices through the tissue, the wound is called____ Answer cut or incision Q. The manual compression of the neck by any body part or tightening a cord-like object around the neck. Answer strangulation 4 Q. A wound caused by rubbing the skin or mucous membrane Answer abrasion Q. The tearing away of a structure or part Answer avulsion Q. Superficial discoloration due to hemorrhage into the tissues from ruptured blood vessels beneath the skin surface Answer bruise Q. A bruise; injury to tissues without breakage of skin Answer contusion Q. A hemorrhage spot or blotch, larger than petechial. Answer ecchymosis Q. A localized collection of extravasated blood, usually clotted in an organ, space or tissue Answer hematoma Q. The escape of blood from a ruptured vessel, which can be external or internal Answer hemorrhage 5 Q. A cut or wound made by a sharp instrument Answer incision Q. The act of tearing or splitting Answer laceration Q. A broad term referring to any pathologic or traumatic discontinuity of tissue or loss of function of a part Answer lesion Q. An injury caused by an object that leaves a distinct pattern of the skin and or organ. Answer patterned injury Q. Injuries, usually bruises and fractures, in various stages of healing. Answer pattern of injuries Q. Minute, pinpoint, non-raised, perfectly round, purplish red spots caused by intradermal or submucous hemorrhage/ Answer petechiae 6 Q. The act of piercing or penetrating with a pointed object or instrument Answer puncture Q. A penetrating, sharp, cutting injury that is deeper than is wide Answer stab wound Q. Loss of hair from pulling and yanking or by other traumatic means Answer traumatic alopecia Q. A general term referring to a bodily injury caused by physical means Answer wound Q. A chronic progessive disease that is not curable but highly preventable Answer alcoholism Q. A maladaptive pattern of substance use with one or more of the following events in a year: Answer -recurrent substance use resulting in failure to fulfill major role obligations, -recurrent substance use in situations where it is hazardous, -recurrent substance related legal problems, -continued substance use despite having social problems. substance abuse 7 Q. A maladaptive patter of substance use with 3 or more of the following is a year: Answer -tolerance, -withdrawal, -the substance being taken in larger amounts, -the use is continued despite the knowledge of the problem. substance dependence Q. The need for markedly increased amounts of the substance to achieve intoxication or desired effect. Answer tolerance Q. Mainly done with pediatric patients, looking at different focus tests to tell you if the child is where they should be in their developement Answer developmental assessment Q. Test that detects developmental delays in infants and preschoolers Answer denver 2 testing tool Q. Assess the patients level of functioning, especially on the patients that are getting ready to go home. Answer functional assessment Q. Loss of abnormality of structure or functions Answer impairment 8 Lack of ability to perform activity in a way that is considred normal disability Disadvantage caused by an impariement that interferes with a persons normal role handicap Legal disability refers to inability to provide for basic needs incapacity behavior or conditions that impair a persons ability to do ADL functional limitation basic tasks necessary for living such as feeding, bathing, and walking ADL life management tasks, such as shopping, telephone use, laundering, etc IADLS looking for nutritional parameters for optimal health, malnutrition, overeating patterns. nutritional assessment test used to detect iron defeciency hemoglobin test test evaluating the fat metabolism cholesterol assesses the quality of sleep sleep assessment assessing the cultural beliefs, customs, background cultural assessment the balance of a person both within ones being and in the outside world health 9 the loss of a persons balance within ones being and the outside world illness all persons who were granted lawful permanent residence legal resident the conferring of citizenship upon a person after birth naturalization an alien who seeks temporary entry to the US for a specific purpose non-immigrant an alien appearing to be inadmissible to the inspecting officer parolee an alien admitted to the US as a lawful permanent resident permanent resident alien a person who is outside his or her country of nationality who is unable or unwilling to return because of persecution or a well founded fear of persecution refugee the unusual and disproportionate frequency of a given health problem within a population when compared with other populations health disparity a concept that describes professional health care that is culturally sensitive cultural care implies that caregivers possess some basic knowledge and constructive attitudes toward the diverse cultural populations found in the setting in which they are practicing culturally sensitive implies that the caregivers apply the underlying background knowledge that must be possessed to provide a given person with the best possible health care culturally appropriate implies that caregivers understand and attend to the total context of the individuals situation culturally competent 10 a concept that describes the degree to which ones lifestyle. heritage consistency living within the norms of the traditional culture traditional heritage consistency acculturated to the norms of the dominant society modern heritage consistency the thoughts, communications, actions, beliefs, values, and institutions of racial ethnic religious or social groups culture pertains to a social group within the social system that claims to possess variable traits such as common geographic origin, migratory status, religion, etc ethnicity a belief in a divine or superhuman power or powers to be obeyed and worshipped as the creators and rulers of the universe religion born out of each persons unique life experiences and his or her personal effort to find purpose and meaning in life spirituality the process of being raised within a culture and acquiring the characteristics of that group socialization the process of adapting to and acquiring another culture acculturation the process by which a person develops a new cultural identity and becomes like the members of the dominant culture assimilation dual pattern of identification and often divided loyalty biculturalism 11 disease causation may be viewed in 3 major ways, biomedical or scientific, naturalistic holistic, or magicoreligious perspective traditional cause of illness based on the assumption that all events in life have a cause and effect. follows the germ theory biomedical or scientific idea found most among american indians, asians, and others who believe that human life is only one aspect of nature and a part of the general order of the cosmos. naturalistic or holistic belief that is the basic premise being the world is seen as an arena in which supernatural forces dominate, the fate of the wold and those in it depends on the action sof supernatural forces for good or evil magicoreligious subjective data obtained to help identify drinking problems and those persons who need a more thorough assessment. alcohol use disorders identification test ADL Activities of daily living IADLS Intsrumental activities of daily living test that measures ADLS based on 1 point or 0 points in relation to bathing, dressing, toileting, transferring, continence, and feeding. KATZ test for IADLS that is a checklist of eight items LAWTON measurements; most commonly used are height, weight, triceps skin fold thickness, elbow breath, arm and head circumference anthropometric measures body weight as a percentage of ideal body weight : current weight / ideal weight X 100 derived weight measure 12 weight (kg) / height (m)2. weight (lbs) / height (in)2 marker of optimal weight for height body mass index BMI being less than 18.5 underweight BMI 18.5-24.9 normal weight BMI 25-29.9 overweight BMI 30.0-39.9 obesity BMI greater than 40 extreme obesity assess the body fat distribution as indicator of health risk waist to hip ratio waist circumference / hip circumference waist to hip ratio estimates the body fat stored or extent of obesity or undernutrition skin fold thickness estimates skeletal muscle and fat stored mid upper arm circumference used to determine range of ideal body weight, uses elbow breadth to determine frame size LAB: shows plasma glucose level or amount of glucose in the serum; managing diabetes glucose 13 LAB: used to detect iron deficiency, shows percent of hemolgobin on RBC hemoglobin LAB measure of cell volume and iron status hematocrit LAB measure of blood fats. used to screen for hyperlipidemia and risk for coronary artery disease triglycerides LAB common measure of visceral protein status, indicator of long term protein status rather than acute protein malnutrition. serum albumin LAB measures iron transport protein by measurement of iron binding capacity. serum transferrin LAB shows acute changes in protein status and sudden demands on protein synthesis prealbumin LAB plasma protein marker of inflammatory status produced by the liver. used to measure metabolic stress and to determine when to bring nutritional support in critically ill pts. c-reactive protein assessment used in addition to a complete assessment focus assessment data of measurements such as data objective data data of what the pt states. subjective data info in the history that is about the pt and unrelated to the CC current health informaton the patient is what kind of source primary source the family, SO, etc is what kind of source for info 14 secondary source looking at current charts, old charts, records from other facilities, etc. review of records a communication process focusing on the patients physical, psycho-social and development, cultural and spiritual responses amenable to care. PURPOSE IS TO OBTAIN DATA. interview phase of interview where you state your name and role introduction phase of the interview where you develop rapport working phase phase of the interview where you summarize the data, interpret or repeat what they said to clarify and validate problems and goals. closing phase assessment technique of looking inspection assessment technique of pushing palpation assessment technique of tapping percussion assessment technique of listening auscultation assessment technique: uses the senses of seeing, hearing, and smelling to get information inspection assessment used to find organ borders, determine the density of a structure, detecting abnormal masses, and eliciting a deep tendon reflex percussion tapping the hand or fingertip directly against the body surface, used to assess tenderness or pain 15 direct percussion placing the middle finger of one hand on the area to be percussed. then using the middle finger of your dominant hand to tap on this finger, flexing the wrist to give a quick brisk tap indirect percussion using the hand to tap, using the ulnar surface or fist. blunt percussion long, low hollow sound resonance loud and high pitched sound, lasts the longest tympany soft, high pitched thud like sound dullness simliar to dull, but very short duration and much softer flatness long, much louder sound, low pitched, booming quality hyperressonance assessment technique used to feel for textures, temperatures, moisture, location, consistency of skin, and underlying structures. palpation using the fingertips to press gently lightly rubbing to feel for pulsations, vibrations, fine bumps, texture differences light palpation increased pressure using flat part of fingers, to detect masses, pain, and organs. medium/ deep palpation this technique uses two hands in severl ways, placing dominant hand flat on the body and the other hand on top of it bimanual palpation 16 trapping palpation using two hands to feel a mass or object between the two trapping using a stethoscope to listen to the body. auscultation part of stethoscope used for low pitched sounds bell part of stethoscope used for high pitched sounds diaphragm body structure of average height, well developed muscles, and flat abdomen. mesomorph body structure being tall, willowy, poorly developed muscle ectomorph body structure being short, stocky, wide costal angle, likely to become obese. endomoroph LOC awake or readily aroused, oriented, and full away of xternal and internal stimuli responding appropriately alert LOC not fully alert, drifts off to sleep when not stimulated, can be aroused to name when called but looks drowsy. lethargic obtunded LOC spontaneously unconscious, responds only to persistant and vigorous shake and pain stupor LOC completely unconscious, no response to pain or stimuli coma 17 clouding of consciousness, inattentive. acute confusional state mood abnormality: lack of emotional response, no expression of feelings, voice monotoous and face immobile. flat affect mood abnormality: sad, gloomy, dejected. depression mood abnormality: loss of identity, feels estranged depersonalizaton mood: joy and optimism, overconfidence, increased motor activity elation mood: excessive well being, unusually cheerful or elated, which is innappropriate considering physical or mental condition euphoria mood: worried uneasy apprehension anxiety mood: annoyed, easily provoked, impatient irritability mood: furious and loss of control rage mood: the existance of opposing emotions toward an idea, object, or person ambivalence mood: rapid shift of emotions lability fabricates events to fill memory gaps confabulation 18 abrupt change or rapid skipping form one topic to another flight of ideas incoherent mixture of words, phrases, and sentences. word salad imitation and repeating of others words or phrases, often with a mumbling echolalia word choice based on a sound not on a meaning clangin the largest organ of the body skin the most rapidly growing cancer in the world melanoma the warning signs of melanoma (ABCDE) asymmetry, border, color, diameter, evolution blue color to light skinned people and ashy gray to darker skin tones cyanosis lack of color to face pallor redness associated with heat erythema bruising ecchymoses purple pinpoint spots petechiae yellow color jaundice 19 swelling and pain at sight edema patchy areas of lighter skin vitiligo refers to the elastic nature of the skin and can indicate hydration turgor or mobility circular lesion annular lesion lesion shaped like a half moon arciform lesion shaped like a disk, clear in the middle discoid lesion that is a circle within a circle (lymes disease) iris or target lesion that is inflammatory response causing vesicles to crust eczamatoid thickening of the skin lichenification lesions in a line linear linear lesion arrangement along nerve herpetiform thich tough or waxy rough lesion keratotic snake like lesion serpiginous 20 lesion arranged in lacy network reticulated lesions that are star like tekangeictatic lesions in clusters grouped grouped in circular lesions polycyclic lesions that run together, looks like one big one confluent lesions that have more than one type or shape multiform lesion lesions with papules and plaques with scaling papulosquamous widespread lesion all over the body generalized lesion where entire body is involved universal irregular distribution or a geographic patterned lesion bizarre single lesion discrete lesion caused by a response to some change in the internal or external environment primary lesion lesion that comes about due to trauma, infection , chonicity, or changes in the initial primary lesion 21 secondary lesion lesion that are red pigmented lesions indicating bleeding vascular lesion hair loss alopecia male and female pattern baldness androgenic alopecia hair loss when the immune system attacks the hair follicles alopecia areata all of the scalp hair is lost alopecia totalis loss of all hairs on the entire body alopecia universalis hair is brittle from hair chemicals chemical alopecia breaks off due to prolonged traction traction alopecia permanent localized loss associated with scarring cicatrical alopecia generalized loss of hair due to chemotherapy drug or radiation alopecial general thinning of hair or balndess syphilitic alopecia erythmatous papules or plaques without hair mucinosis alopecia 22 done on nails to check the oxygen status of pt. capillary refill nail color due to anemia white nails nail color due to fungal infection yellow nail nail color from pseudomonas infection green or black nail nail color with red streaks indicating bacterial endocarditis splinter hemorrhages nail color from mild trauma, infection , or zinc deficiency white spots pinhead size depressions from nail matrix inflammation pitting of the nail transverse ridges on nail associated with malnutrtion, anemia, infection, picking beaus lines thin spoon shaped nails caused by iron deficiency, diabetes, protein deficiency etc. spoon nails nail thickening or hypertrophy can be causedby trauma, psoriasis, fungal infeciton onychauxis liver failure indication in nail where there are large white areas and smaller regular band terry nail renal failure indicator with half white area on nail and half normal . half and half nails LOC transitional state between lethargy and stupor, sleeps most of time, difficult to arouse. obtunded 23 small head microcephalic big head macrocephalic elongated bones, jaw, forehead, lips and nose acromegaly fluid accumulation round the brain causing head to englarge in babies hydrocephalus round oval movable rubbery cyst in head subaceous cyts swishing rushing or blowing sounds bruits protrusion of eyes exopthalmia swelling around eyes periorbital edema nerve pain to the face tic deloureaux fixed nonmobile expression shows no emotion flat affect shifts rapidly between moods and facial expressions labile affect hollow suken cheeks and eyes cachexic round face red cheecks cushings 24 blue circles under eyes, open mouth allergic facies facial changes including dull skin, round swollen face and eyes myxedema how many occipital lymph nodes 2 how many tonsilar lymph nodes 2 how many pre auricular lymph nodes 2 how many post auricular lymph nodes 1 how many submandibular lymph nodes 2 how many submental lymph nodes 1 how many anterior cervical chain lymph nodes 3 how many deep cervical chain lymph nodes 4 how many post superficial cervical lymph 5 how many posterior cervical chain lymph nodes 3 how many supravlavicular lymph nodes 25 291

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