Nursing The Person With Althered Physical Health Bn805

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1. An appropriate nursing intervention for a patient with pneumonia with the nursing diagnoisis of ineffective airway clearance related to thick secretions would be

Explanation

Teaching the patient how to cough effectively to bring secretions to the mouth is an appropriate nursing intervention for a patient with pneumonia and ineffective airway clearance related to thick secretions. This intervention helps the patient to effectively clear their airway by coughing and expelling the thick secretions. By teaching the patient the correct technique, they can actively participate in their own care and improve their airway clearance, which can ultimately help in preventing complications and promoting recovery.

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Nursing The Person With Althered Physical Health Bn805 - Quiz

This quiz for 'Nursing the person with altered physical health BN805' assesses key competencies in respiratory assessment techniques, including understanding and identifying different lung sounds, pulse oximetry, and... see moretactile fremitus. It is essential for nursing students and professionals aiming to enhance patient care skills. see less

2. Where does the hearts electrical stimulus originate from?

Explanation

The sino-atrial (SA) node is responsible for initiating the electrical stimulus that controls the heart's rhythm. It is located in the right atrium of the heart and acts as the natural pacemaker. The SA node generates electrical impulses that spread through the atria, causing them to contract and pump blood into the ventricles. From there, the electrical signal travels to the Bundle of His, the right bundle branch, and the Purkinje fibers, which distribute the stimulus to the ventricles, causing them to contract and pump blood out of the heart.

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3. When ausculating heart sounds, what do you assess?

Explanation

When auscultating heart sounds, you assess the presence of rubs or murmurs, the rhythm, and the rate. This means that you listen for any abnormal sounds such as rubbing or whooshing sounds, you observe the regularity of the heartbeat, and you determine the number of beats per minute. By assessing all of these factors, you can gather important information about the overall health and function of the heart.

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4. Which will you observe each time you check your patients's IV site?

Explanation

When checking a patient's IV site, it is important to observe for moisture and any oozing, as this could indicate a leak or infection. Additionally, one should make sure the dressing is not loose, as a loose dressing can increase the risk of contamination and dislodgement of the IV. Lastly, any bleeding around or on the dressing should be noted, as it could be a sign of a complication or injury at the site. Therefore, the correct answer is A, B, and D.

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5. To accurately assess the carotid pulse

Explanation

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6. The Glasgow Coma Scale (GCS) is used to evaluate

Explanation

The Glasgow Coma Scale (GCS) is a tool used to assess the level of consciousness in a person. It evaluates the individual's ability to open their eyes, respond to verbal commands, and demonstrate motor responses. By assessing these factors, healthcare professionals can determine the severity of a brain injury or neurological condition. The GCS helps in monitoring and tracking changes in consciousness over time, allowing for appropriate medical interventions and treatment plans to be implemented.

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7. The nurse detects a possible irregularity in the rhythm of a client's pulse and will

Explanation

When a nurse detects a possible irregularity in the rhythm of a client's pulse, counting the client's apical pulse for a full minute is the appropriate action. The apical pulse is measured by placing the stethoscope on the chest over the apex of the heart and counting the number of beats for a full minute. This method provides a more accurate assessment of the heart's rhythm compared to counting the radial pulse. By counting the apical pulse for a full minute, the nurse can gather more comprehensive information about the client's heart rate and rhythm, which can help in identifying any irregularities or abnormalities.

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8. You are working with a client who has respiratory disease.  You find that this client is able to breathe only in an upright or standing position.  In charting, you could describe the diffiuclty breathing in any psoition other than an upright or standing positon, or you could use the term for this condition, which is -

Explanation

Orthopnea is the term used to describe the difficulty in breathing in any position other than an upright or standing position. This condition is commonly seen in individuals with respiratory diseases. Bradypnea refers to abnormally slow breathing, tachypnea refers to abnormally rapid breathing, and eupnea refers to normal breathing.

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9. When collecting subjective data froma person during a neurological assessment, you will ask about

Explanation

During a neurological assessment, it is important to collect subjective data from the person to understand their symptoms and potential neurological issues. Headaches can be indicative of various neurological conditions. Tingling or numbness can be a sign of nerve damage or compression. Difficulty swallowing can be a symptom of a neurological disorder affecting the muscles involved in swallowing. Therefore, asking about all of these symptoms is necessary to gather comprehensive subjective data for a neurological assessment.

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10. Age-related changes that may alter cardiovascular health include

Explanation

As individuals age, their cardiovascular health can be affected by several changes. Firstly, there may be a decrease in S-A node cells, which are responsible for initiating the electrical signals that regulate heart rhythm. Additionally, calcification can occur in the mitral or aortic valves, which can lead to valve dysfunction and affect blood flow. Lastly, venous distention, or the swelling of veins, can also occur with age, potentially impacting cardiovascular health. Therefore, all of the above changes can alter cardiovascular health as individuals age.

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11. Your understanding of creps, rales or crackles is

Explanation

The given correct answer states that creps, rales, or crackles are created when air is moving through smaller air passages narrowed by mucous or pus. This suggests that these abnormal lung sounds are indicative of an obstruction or blockage in the air passages, which could be caused by conditions such as bronchitis, pneumonia, or asthma. This explanation aligns with the medical understanding of creps, rales, and crackles as abnormal lung sounds that occur due to the presence of fluid or inflammation in the airways.

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12. Which of the following best describes the term localised

Explanation

The term "localized" refers to something that occurs in a specific area or region. In this context, it means that something is happening at or around the site where an IV (intravenous) insertion has taken place. This could refer to any symptoms, complications, or reactions that are specific to the area where the IV was inserted.

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13. The best technique for checking tactile fremitus is to use the ulnar surface of the hand

Explanation

The ulnar surface of the hand is the best technique for checking tactile fremitus because it is the most sensitive area for detecting vibrations in the chest. When the person being examined speaks, these vibrations can be felt through the ulnar surface, providing valuable information about the condition of the lungs and underlying tissues. This technique is commonly used by healthcare professionals to assess for abnormalities such as fluid in the lungs or consolidation.

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14. IV tubing must be changed every 72 hours

Explanation

IV tubing must be changed every 72 hours to prevent the risk of infection. Over time, bacteria can grow in the tubing, increasing the chance of contamination and infection. Changing the tubing regularly helps maintain a sterile environment and ensures the safety of the patient receiving the IV fluids. Therefore, the statement is true.

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15. Possible age-related changes which may affect ventilation include

Explanation

As individuals age, several changes occur in the respiratory system that can affect ventilation. The loss of elastic fibers in the lungs leads to decreased lung compliance, making it harder for the lungs to expand and contract efficiently. Calcification in the rib cartilage can restrict chest wall movement, further limiting the ability to breathe deeply. Reduced ciliary activity in the respiratory tract impairs the clearance of mucus and debris, increasing the risk of respiratory infections. Therefore, all of the given options - loss of elastic fibers in the lungs, calcification in the rib cartilage, and reduced ciliary activity - can contribute to age-related changes that affect ventilation.

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16. Assessment of the neurogoic system includes the following areas

Explanation

The correct answer is "all of the above" because the assessment of the neurogoic system includes evaluating sensory and motor function, reflexes, mental and emotional status, and cranial nerve assessment. This means that in order to fully assess the neurogoic system, all of these areas need to be examined.

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17. Normal duration of the PR interval is

Explanation

The normal duration of the PR interval is 3-5 small squares (0.12-0.20 seconds). This indicates the time it takes for the electrical signal to travel from the atria to the ventricles in the heart. A PR interval within this range is considered normal and suggests that the conduction system of the heart is functioning properly.

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18. Which perpheral pulse may be palpated at the upper surface of the foot?

Explanation

The correct answer is Dorsalis Pedis. The Dorsalis Pedis pulse can be palpated on the upper surface of the foot. This pulse is important for assessing blood flow to the foot and is commonly checked during physical examinations.

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19. Which of the following statements are true of a hypertonic solution? a) draws water out of the cells and intestitial space and into the intravascular space b) has a higher osmotic pressure than the blood c) has a lower osmotic pressure than the blood d) dextrose 10% and 50% in water are examples of a hypertonic solution

Explanation

A hypertonic solution is a solution that has a higher concentration of solutes compared to the cells and interstitial space. This causes the solution to draw water out of the cells and interstitial space and into the intravascular space, resulting in cell shrinkage. Additionally, a hypertonic solution has a higher osmotic pressure than the blood, meaning that it exerts a greater force to draw water towards it. Finally, examples of hypertonic solutions include dextrose 10% and 50% in water. Therefore, the correct statements are a, b, and d.

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20. Having the client/patient stand with feet together and eyes closed is a test of

Explanation

Having the client/patient stand with feet together and eyes closed is a test of cerebellar function. The cerebellum is responsible for coordinating voluntary movements, maintaining balance, and controlling posture. This test, known as the Romberg test, assesses the cerebellum's ability to integrate sensory information from the proprioceptors in the muscles and joints to maintain balance. If the client/patient sways or loses balance with their eyes closed, it suggests dysfunction in the cerebellum.

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21. Pulse oximetry measures

Explanation

Pulse oximetry measures arterial oxygen saturation. This is the percentage of oxygen bound to hemoglobin in the arterial blood. It is an important parameter to monitor the oxygen levels in the body and can help in assessing the respiratory and circulatory function. By placing a sensor on a finger, toe, or earlobe, pulse oximetry can quickly and non-invasively provide a measurement of arterial oxygen saturation. It is commonly used in medical settings, especially during surgeries, to ensure that the patient is receiving enough oxygen.

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22. When you are ausculating Mrs Rose's chest , you hear low-pitched, coarse sounds primarily on expiration. This best describes

Explanation

When auscultating Mrs. Rose's chest and hearing low-pitched, coarse sounds primarily on expiration, this indicates the presence of rhonchi (or sonorous wheezes). Rhonchi are caused by airway obstruction due to mucus or other secretions, leading to a turbulent airflow and resulting in low-pitched sounds. These sounds are typically heard more prominently during expiration. Sibilant wheezes, on the other hand, are high-pitched sounds heard during both inspiration and expiration, often associated with asthma or bronchospasm. Crackles are discontinuous, non-musical sounds heard during inspiration and can indicate fluid or inflammation in the lungs. Pleural friction rub is a grating, scratchy sound caused by inflamed pleural surfaces rubbing together, typically heard during both inspiration and expiration.

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23. The posterior tibial pulse may be palpated o the inner (medial) aspect of the ankle -

Explanation

The posterior tibial pulse can be felt on the inner (medial) side of the ankle. This is a true statement.

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24. What is the most reliable indicator of a change in neurologic status in a conscious patient?

Explanation

The level of consciousness is the most reliable indicator of a change in neurologic status in a conscious patient. Changes in consciousness, such as confusion, disorientation, or loss of consciousness, can indicate a variety of neurologic conditions or injuries. Monitoring the level of consciousness allows healthcare providers to assess the patient's neurologic function and determine the appropriate course of action. Pupil reaction, motor strength, and cranial nerve abnormalities can also provide valuable information, but they may not be as reliable or sensitive as changes in the level of consciousness.

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25. When the nurse gathers baseline information on a client, the nurse will check the bp in both arms to detect deficits. There should be no more than how many mmHg difference between the two?

Explanation

When the nurse gathers baseline information on a client, checking the blood pressure in both arms is important to detect any deficits. The nurse should look for no more than a 15 mmHg difference between the blood pressure readings in the two arms. This is because a significant difference in blood pressure between the arms could indicate underlying cardiovascular problems or arterial blockages. Therefore, it is crucial for the nurse to assess and compare the blood pressure in both arms to ensure accurate baseline information and identify any potential health issues.

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26. You are testing the corneal reflex on a 14 year old boy with normal vision. He displays no blinking to corneal touch.  This is an abnormal finding.

Explanation

The corneal reflex is a protective reflex that causes blinking in response to any touch or irritation of the cornea. It is mediated by the trigeminal nerve (cranial nerve V). In a normal individual, the corneal reflex should be present and cause blinking when the cornea is touched. However, in this case, the 14-year-old boy with normal vision does not display any blinking to corneal touch, which is an abnormal finding. Therefore, the correct answer is true.

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27. An S3 or S4 is generally indicative of heart failure in an adult

Explanation

An S3 or S4 heart sound is typically associated with heart failure in adults. These abnormal sounds occur during the filling phase of the cardiac cycle and indicate impaired ventricular function. The S3 sound, also known as a ventricular gallop, is caused by rapid filling of the ventricles and is often heard in conditions such as congestive heart failure. The S4 sound, also known as an atrial gallop, occurs when the atria contract forcefully to push blood into a stiff or hypertrophic ventricle. Therefore, the statement that an S3 or S4 is generally indicative of heart failure in an adult is true.

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28. What does the QRS represent?

Explanation

The QRS complex represents the depolarization of the ventricles. Depolarization is the electrical activation of the heart muscle cells, causing them to contract and pump blood. The QRS complex is observed on an electrocardiogram (ECG) as a series of three waves (Q, R, and S) and indicates the electrical activity in the ventricles. The depolarization of the Purkinje fibers and the atrial septum are not specifically represented by the QRS complex. Repolarization of the atria is represented by the T wave on the ECG.

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29. Increases in the resting pulse rate are associated with all of the following EXCEPT

Explanation

Increases in the resting pulse rate are associated with infection and fever, decreases in blood pressure secondary to shock, and sympathomimetic drugs. However, parasympathetic nervous system stimulation typically causes a decrease in heart rate, not an increase. Therefore, it is not associated with increases in the resting pulse rate.

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30. Which of the folloing are the most common problem with IV therapy

Explanation

Both A and C are the most common problems with IV therapy. When the needle is out of place, it can cause difficulties in administering the fluids or medication correctly, leading to ineffective treatment. On the other hand, if the site where the IV is inserted becomes red, sore, or swollen, it indicates an infection or inflammation, which can also hinder the effectiveness of the therapy and potentially cause further complications.

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31. When percussing over normal lung fields, the sound you would expect to hear would be

Explanation

When percussing over normal lung fields, the sound you would expect to hear is "resonate." Resonance is the normal sound produced when percussing over healthy lung tissue. This sound indicates that the air-filled lungs are vibrating freely and producing a clear, hollow sound. Dullness, sonorousness, and crackling are not the expected sounds over normal lung fields and may indicate abnormalities such as consolidation, fluid accumulation, or lung tissue damage.

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32. Mrs Jones has been admitted to your unit complaining of left sided weakness and difficulty speaking.  From the following assessments, identify the data that BEST represents a NURSING assessment

Explanation

The data "unable to communicate basic needs and perform hygiene measures with left hand" represents a nursing assessment because it focuses on the patient's functional abilities and limitations related to their left-sided weakness and difficulty speaking. This information helps the nurse understand the patient's specific needs and develop a care plan to address them.

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33. Hypotonic is a term which means that a solution has

Explanation

Hypotonic refers to a solution that has a lower osmotic pressure than the blood. Osmotic pressure is the measure of the concentration of solutes in a solution, and a lower osmotic pressure means that the solution has a lower concentration of solutes compared to the blood. This can cause water to move into the cells, potentially leading to cell swelling or bursting.

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34. A person should he able to maintain his/her balance when standing on one foot for

Explanation

A person should be able to maintain their balance when standing on one foot for 5 seconds on either side because this demonstrates good stability and control over their body. Being able to balance equally on both sides indicates a well-developed sense of proprioception and core strength. It also suggests that the person has good coordination and is able to distribute their weight evenly. The ability to touch one's nose while balancing is not mentioned in the question and therefore not relevant to the correct answer.

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35. Which of the following statements accurately describes a pulse deficit

Explanation

both apical and radial pulse should be the same

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36. Which of the following statements about using the bell of stethoscope to assess heart sounds is correct?

Explanation

The correct answer is that the bell of the stethoscope must be placed lightly on the skin. The bell is the smaller side of the stethoscope, and it is designed to detect low-frequency sounds such as murmurs or rubs. Placing it lightly on the skin allows for better conduction of these sounds and helps to minimize any interference or distortion. Pressing too hard may dampen the sounds or make it difficult to hear them accurately. Therefore, it is important to use the bell of the stethoscope with a light touch for assessing heart sounds.

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37. Mr Toms aged 28 years was admitted the previous evening following a concussion while playing rugby. The RN asks you the following questions. What are the four qauick elements of a neurological check

Explanation

The four quick elements of a neurological check are orientation, memory, pupils, and motor strength. These elements are important in assessing the overall neurological function of a patient. Orientation refers to the patient's awareness of person, place, and time. Memory assessment helps determine the patient's ability to retain and recall information. Pupil examination provides information about the function of the cranial nerves and can indicate potential brain injury. Motor strength assessment evaluates the patient's ability to move and control their muscles, which can indicate any motor deficits or abnormalities.

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38. Mary L aged 48 has been taking antihypertnesive medication for 6 months.  Recently she experiences a "near fainting" episode. Whcih of the following statements will best guide the nurse assessing Mary?

Explanation

The nurse should assess Mary's blood pressure in different positions (supine, sitting, and standing) because this will provide a comprehensive evaluation of her blood pressure and help determine if she has postural hypotension. By assessing her blood pressure in these positions, the nurse can identify any significant changes in systolic pressure, such as a fall of 5-15 mmHg, which would indicate postural hypotension. This information will guide the nurse in understanding the cause of Mary's near fainting episode and developing an appropriate plan of care.

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39. What does the T wave represent

Explanation

The T wave on an electrocardiogram represents ventricular repolarization. It shows the recovery of the ventricles after they have contracted during ventricular depolarization. This phase allows the ventricles to relax and prepare for the next heartbeat. The T wave is an important indicator of the electrical activity of the heart and can provide information about the overall health and function of the ventricles.

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40. Which of the following indicates the normal location of the apical pulse in an adult?

Explanation

The correct answer is "fifth left intercostal space, medial to mid-clavicular line." The apical pulse is located at the fifth intercostal space, which is the space between the ribs, on the left side of the chest. It is specifically located medial to the mid-clavicular line, which is an imaginary line drawn vertically down the middle of the clavicle. This is the standard location for measuring the apical pulse in adults.

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41. When taking a bp which of the following is INCORRECT

Explanation

The statement "remember that a systolic of 100 plus age in years is normal" is incorrect because it is not a universally accepted guideline for determining normal blood pressure. Blood pressure can vary greatly among individuals and is influenced by various factors such as overall health, lifestyle, and medical conditions. Therefore, it is important to consider a range of factors when assessing blood pressure and not rely solely on a formula based on age.

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42. James Feld, aged 67 years, experienced a cerebrovasuclar accident (CBA). He is able to answer yes or no to simple questions, but has difficulty speaking.  His words are difficult to understand, although he continues to make efforts to speak. Mr Feld is most likely experiencing

Explanation

James Feld's difficulty in speaking, despite being able to answer yes or no to simple questions, suggests that he is experiencing Broca's, or motor aphasia. This condition is characterized by difficulty in producing speech due to damage to the frontal lobe of the brain, specifically Broca's area. It affects the ability to form words and sentences, but comprehension and understanding of language remain intact. This explains why Mr. Feld's words are difficult to understand, but he continues to make efforts to speak.

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43. When assessing John C, aged 64, who has chronic obstructive lung disease, the nurse assesses tactile fremitus

Explanation

The correct answer explains that fremitus is increased when the transmission of sound is increased, as through consolidation of lobar pneumonia. This means that when there is consolidation in the lungs due to lobar pneumonia, the transmission of sound is enhanced, resulting in increased fremitus. This information is relevant when assessing John C, who has chronic obstructive lung disease, as it helps the nurse differentiate between the two conditions based on the tactile fremitus assessment.

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44. Mr Pain was admitted to coronary care with a diagnosis of myocardial infarction. 2 days follwoing Mr Pain has a temp of 37.9 degress. The nurse should

Explanation

The correct answer is to record the temperature and monitor vital signs at routine intervals. This is because a temperature of 37.9 degrees Celsius is slightly elevated but not significantly high. It is important to monitor the temperature and vital signs regularly to assess for any changes or worsening of the patient's condition. Encouraging deep breathing and coughing every 2 hours may be beneficial for preventing complications such as pneumonia, but it is not specifically indicated in this situation. Auscultating the chest for diminished breath sounds may be relevant in assessing respiratory function, but it is not the most appropriate action to take based solely on an elevated temperature. Notifying the physician immediately about the temperature is not necessary unless there are other concerning symptoms or signs.

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45. An electrocardiogram (ECG) is ordered for Jack who is complaining of chest pain.  An early finding in the lead over an infarction area would be

Explanation

An early finding in the lead over an infarction area would be elevated or depressed ST segments. This is because an infarction, which refers to the death of heart muscle tissue due to a lack of blood supply, can cause changes in the electrical activity of the heart. The ST segment on an ECG represents the period between ventricular depolarization and repolarization. In the case of an infarction, the ST segment can become elevated or depressed, indicating abnormal electrical activity in the affected area of the heart. This finding can help diagnose and assess the severity of a heart attack.

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46. When assessing cyanosis, the nurse will utilise which of the following guiding principles?

Explanation

Sluggish or reduced blood flow contribute to peripheral cyanosis because when blood flow is compromised, there is less oxygenated blood reaching the peripheral tissues. This can occur due to factors such as vasoconstriction, decreased cardiac output, or obstruction of blood vessels. As a result, the tissues in the extremities, such as the fingers, toes, and lips, may appear bluish or cyanotic. Central cyanosis, on the other hand, is caused by decreased oxygen saturation in the arterial blood and is best identified by observing the lips, tongue, and oral mucosa.

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47. Which blood type is the "universal donor"

Explanation

O- is considered the "universal donor" blood type because it lacks the A or B antigens on the surface of its red blood cells. This means that O- blood can be transfused to individuals with any blood type, as it is less likely to cause an immune reaction. Additionally, O- blood is compatible with both Rh positive and Rh negative blood types, making it suitable for a wider range of recipients.

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48. Mr James, age 75 is admitted to the hospital with shortness of breath(SOB), a temp of 40degrees and substernal chest pain. He has a history of emphysema and a recent upper respiratory infection. You ausultate a low-pitched grating sound over his left anterior chest that persists even when he holds his breath. You suspect which of the following?

Explanation

Based on the given information, Mr. James is presenting with symptoms such as shortness of breath, high temperature, substernal chest pain, and a history of emphysema and upper respiratory infection. The low-pitched grating sound heard over his left anterior chest that persists even when he holds his breath suggests a pericardial friction rub. A pericardial friction rub is a classic sign of pericarditis, which is inflammation of the pericardium (the sac surrounding the heart). This condition can cause chest pain and difficulty breathing, which aligns with Mr. James' symptoms.

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49. Pain responses, both psychological and physiological, are initiated at the

Explanation

Pain responses, both psychological and physiological, are initiated at the cortical level. This means that the brain's cortex is responsible for processing and experiencing pain. The cortex is the outer layer of the brain and plays a crucial role in sensory perception, including the perception of pain. It receives and interprets signals from various parts of the body, including the nerves that transmit pain sensations. Therefore, the correct answer is cortical level.

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50. Which of the following statements regarding arterial pulses is INCORRECT?

Explanation

The posterior tibial pulse is actually palpated on the inner aspect of the ankle, not the outer aspect.

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51. Which of the following statements regarding percussion is INCORRECT?

Explanation

Percussion is a technique used in physical examination to assess the underlying structures of the body by tapping on the body surface. It can help in detecting fluid or air in a cavity and determining the position, size, and density of underlying structures. However, it does not require the patient to say "99" or "a" during percussion. This statement is incorrect as it does not align with the actual procedure of percussion.

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52. Hemianopsia (or hemianopia)

Explanation

Hemianopsia, also known as hemianopia, refers to the loss of peripheral vision on either the right, left, or both sides. This condition is not associated with dysfunction of cranial nerve three or eight, and it does not refer to the loss of vestibular function. Hemianopsia occurs due to damage or injury to the visual pathways in the brain, typically in the occipital lobe. This can result from various causes such as stroke, brain tumors, or trauma. Individuals with hemianopsia may have difficulty seeing objects or people on the affected side, leading to potential safety concerns and challenges with daily activities.

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53. The nurse notes that thoracic expansion is greater on the left side than the right and -

Explanation

The nurse refers the client to a physician for additional examination because the observation of greater thoracic expansion on the left side than the right could indicate a potential underlying issue or abnormality. It is important to have a physician assess the client to determine the cause of this asymmetry and to rule out any potential health concerns.

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54. Which of the following should be charted on the patient's health record? a) length and gauge of the infusion device b) site of venipuncture c) date and time of insertion d) patient's response to the procedure

Explanation

The length and gauge of the infusion device should be charted on the patient's health record because this information is important for monitoring the patient's treatment and ensuring proper care. The site of venipuncture should also be recorded as it helps in tracking any potential complications or infections. Additionally, the date and time of insertion are crucial for documenting when the procedure was performed and for tracking any changes or reactions that may occur.

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55. Which anatomic structure slows the spread of electrical current through the myocardium?

Explanation

The atrioventricular (AV) node is responsible for slowing down the spread of electrical current through the myocardium. This is important because it allows for proper coordination between the atria and ventricles during the cardiac cycle. By delaying the electrical signal, the AV node ensures that the atria have enough time to contract and fill the ventricles with blood before the ventricles contract. This delay is necessary for efficient pumping of blood and maintaining proper heart function.

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56. On another patient, Mr Paku you ausculate musical, squeaky sounds bilaterlly in his lung fields.  This is best described as

Explanation

Sibilant wheezes are high-pitched, musical sounds heard during inspiration and expiration. They are typically caused by the narrowing of the airways due to inflammation or constriction. In the case of Mr. Paku, the presence of musical, squeaky sounds bilaterally in his lung fields suggests the presence of sibilant wheezes. These wheezes are commonly associated with conditions such as asthma or bronchitis.

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57. A client is having an ECG to evaluate an atrial dysrhythmia.  To evaluate the atrial depolarization and contraction, the jurse will focus on the client's

Explanation

Study and Know your ECG!!!

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58. Cardiac murmurs
  1. may be caused by high flow rates through normal valves
  2. are generally innocent in older adults
  3. may be caused by forward flow of blood through a constricted valve or into a dilated chamber
  4. may be caused by backward flow through a defective or incompetent valve

Explanation

Cardiac murmurs can be caused by high flow rates through normal valves, forward flow of blood through a constricted valve or into a dilated chamber, and backward flow through a defective or incompetent valve. This means that options 1, 3, and 4 are correct. Option 2, which states that cardiac murmurs are generally innocent in older adults, is incorrect.

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59. Which of the following statements regarding cardiac landmarks and auscultation is CORRECT?

Explanation

The forward sitting and left lateral decubitus positions are commonly used during cardiac auscultation to aid in detecting murmurs. In the forward sitting position, the patient leans forward to bring the heart closer to the chest wall, making it easier to hear abnormal sounds. The left lateral decubitus position involves lying on the left side, which can help accentuate certain heart sounds and murmurs. These positions allow for better detection and evaluation of murmurs, making the statement correct.

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60. Which of the following statements is correct regarding an arterial bruit

Explanation

An arterial bruit is a high-pitched blowing sound that is often indicative of atherosclerosis. Atherosclerosis is a condition where the arteries become narrowed and hardened due to the buildup of plaque. This narrowing can disrupt the smooth flow of blood, causing turbulence and producing the bruit sound. Therefore, the correct statement is that an arterial bruit is often indicative of atherosclerosis.

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61. Factors affecting flow rate of the IV are a) phlebitis b) height of container c) postional IV d) air trapped in tubing

Explanation

The flow rate of an IV can be affected by multiple factors. Phlebitis, which is the inflammation of the vein, can cause a decrease in flow rate. The height of the container plays a role as well, as gravity affects the flow of the fluid. If the IV is positioned in a certain way, it can also impact the flow rate. Additionally, air trapped in the tubing can disrupt the flow. Therefore, the correct answer is a, b, c.

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62. Thrombophlebitis is caused by injury or irritation from which of the following? a) long term therapy b) acidic or alkaline substances c) trauma during insertion d) poor aseptic technique

Explanation

Thrombophlebitis is caused by a combination of factors, including long-term therapy, acidic or alkaline substances, and trauma during insertion. Long-term therapy can lead to the development of blood clots in the veins, while acidic or alkaline substances can cause irritation and inflammation, leading to thrombophlebitis. Additionally, trauma during insertion of medical devices or catheters can damage the veins, increasing the risk of thrombophlebitis. Therefore, a combination of long-term therapy, exposure to acidic or alkaline substances, and trauma during insertion can all contribute to the development of thrombophlebitis.

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63. Which of the following is accurate regarding the S1 heart sound?

Explanation

The S1 heart sound is the first sound heard during the cardiac cycle and is caused by the closure of the mitral and tricuspid valves. It has a lower pitch than the second heart sound. The splitting of the sound is abnormal and indicates a heart condition. The S1 heart sound is normally heard loudest at the apex of the heart, which is the lower left side of the chest.

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64. Auscultation of the lungs should reveal which normal finding?

Explanation

Auscultation of the lungs should reveal vesicular breath sounds in all lung fields posteriorly. Vesicular breath sounds are normal and are heard over most of the lung fields. They are characterized by a soft, low-pitched sound during inspiration and a shorter, higher-pitched sound during expiration. This is the expected finding when auscultating the lungs.

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