NUR 101 - Test 3 - Physical Assessment From Fundamentals Of Success

The correct answer is palpation because when taking a radial pulse, the examiner uses their fingers to feel the pulse at the radial artery, which is located on the inner wrist. This method allows the examiner to assess the rate, rhythm, and strength of the pulse. Inspection, percussion, and auscultation are not appropriate methods for assessing a radial pulse.

Auscultation is the correct physical examination method to assess for borborygmi. Borborygmi refers to the noise caused by the movement of gas in the intestines, and auscultation involves listening to these sounds using a stethoscope. Percussion involves tapping on the body to assess underlying structures, inspection involves visually examining the body for any abnormalities, and palpation involves using touch to feel for abnormalities or assess the texture of organs. However, in the case of borborygmi, listening for the sounds with a stethoscope is the most appropriate method.

The carotid pulse site should not be assessed on both sides of the body at the same time because it is located in the neck, close to major blood vessels that supply blood to the brain. Assessing the carotid pulse on both sides simultaneously could potentially disrupt blood flow to the brain and cause dizziness or fainting. It is important to assess the carotid pulse on one side at a time to ensure accurate and safe measurements.

During an emergency assessment of a patient, airway clearance takes priority. This is because a clear and open airway is essential for the patient's breathing and overall survival. If the airway is blocked or compromised, it can lead to respiratory distress or failure. Therefore, ensuring the patient's airway is clear and unobstructed is the first and most crucial step in providing immediate care and support.

The series of vital signs P 110, R 26, BP 80/60 is most reflective of hypovolemic shock because the heart rate (P) is increased, the respiratory rate (R) is increased, and the blood pressure (BP) is decreased. In hypovolemic shock, there is a decrease in blood volume, which leads to a compensatory increase in heart rate and respiratory rate to try to maintain oxygen delivery to the body. The decreased blood pressure is a result of the decreased blood volume.

a) The apical, not the carotid, pulse should be obtained when the pulse is irregular.

b) This is unnecessary because a stethoscope is adequate.

c) This is necessary to obtain an accurate count. Taking the pulse for 15 seconds and multiplying by 4 or taking the pulse for 30 seconds and multiplying by 2 will result in inaccurate readings and is unsafe.

d) Initially the response should be to obtain an apical rate. Ultimately, the apical and radial rates are compared to determine if there is a pulse deficit.

a) During the compensatory stage of shock, blood is shunted away from, not toward, the periphery. Hyperemia is an increase in blood flow to an area where the overlying skin becomes reddened and warm.

b) The circulating blood volume is reduced by 25 to 35% during the compensatory stage of shock and 35 to 50% during the progressive stage of shock as the peripheral vessels constrict to increase blood flow to vital organs. This shunting of blood causes hypotension

c) With shock, the heart rate increases (tachycardia); it is not irregular. The heart rate increases during the compensatory stage of shock to maintain adequate blood flow to body tissues.

d) During the compensatory stage of shock respiratory rate increases, not decreases, to maintain adequate oxygenation of body cells.

Before obtaining a urine specimen from a patient with a urinary retention (Foley) catheter, the nurse should wear a pair of clean gloves. Wearing gloves is necessary to maintain proper hygiene and prevent the spread of infection. It also helps to protect the nurse from any potential contact with bodily fluids during the procedure.

When taking a blood pressure, it is important to document the position of the patient if the patient is not in a sitting position. This is because the position of the patient can affect the accuracy of the blood pressure reading. The standard position for measuring blood pressure is with the patient sitting upright with their arm supported at heart level. If the patient is in a different position, such as lying down or standing, it can lead to inaccurate readings. Therefore, documenting the position of the patient ensures that the blood pressure reading is taken correctly and can be accurately interpreted by healthcare providers.

During the onset stage of fever, the body tries to increase its temperature to match the set point in the hypothalamus. Shivering is a physiological response to generate heat by increasing muscle activity. This additional adaptation helps to raise the body temperature.

Ensuring that the bladder of the cuff encircles less than 25% of the arm can result in a blood pressure error because it can lead to an inaccurate measurement. The bladder of the cuff needs to fully encircle the arm in order to accurately measure blood pressure. If it does not cover enough of the arm, the pressure reading may be lower than the actual blood pressure.

Shivering would increase heat production because it is a physiological response in which the muscles rapidly contract and relax to generate heat. This increased muscular activity generates heat, which helps to raise the body's temperature.

Assessing vital signs is important when a patient complains of pressure in the chest because it could be a symptom of a serious cardiac condition such as a heart attack. Monitoring vital signs such as blood pressure, heart rate, and oxygen saturation can provide crucial information about the patient's cardiovascular health and help determine the appropriate course of action.

A person with a blood infection would most likely have the highest temperature because infections can cause the body to release chemicals that raise the body's temperature. This is known as a fever, which is a common symptom of many infections. Newborn infants and adolescents who have been doing aerobic exercises may also have slightly elevated temperatures, but a blood infection would likely cause a higher and more significant increase in body temperature. Older adults who have just spent 10 minutes in a warm shower may experience a temporary increase in body temperature, but it would not be as high as that of a person with a blood infection.

The nursing action that is common to all instruments when taking a temperature is to ensure that the instrument is clean. This is a crucial step to prevent the spread of infection and ensure accurate readings. Keeping the instrument clean helps maintain hygiene standards and ensures the safety of the patient. It is important for nurses to follow proper cleaning protocols before and after using any instrument to maintain a sterile environment and minimize the risk of contamination.

A defining characteristic associated with the nursing diagnosis of hyperthermia is a rectal temperature of 101 degrees Fahrenheit. Hyperthermia refers to an elevated body temperature, and a rectal temperature of 101 degrees Fahrenheit indicates a fever. This symptom helps in identifying the nursing diagnosis of hyperthermia as it is a key indicator of increased body temperature. Mental confusion, increased appetite, and decreased heart rate are not specific defining characteristics associated with hyperthermia.

A rectal temperature is used best for a mouth breather because this method provides the most accurate measurement of core body temperature. Oral temperature may not be accurate for a mouth breather due to open mouth breathing, which can affect the reading. Rectal temperature is considered the gold standard for accurate core body temperature measurement as it reflects the internal temperature of the body.

Exacerbation refers to a worsening or flare-up of symptoms associated with a chronic disease. It is characterized by an increase in the severity or frequency of symptoms, which can be temporary or long-lasting. This term is commonly used in the medical field to describe the recurrence or intensification of symptoms in conditions such as asthma, arthritis, or multiple sclerosis. Therefore, exacerbation is the most appropriate term to describe the given scenario of a recurrence of symptoms associated with a chronic disease.

a) The body temperature is on the decline during this time.
b) The body temperature is just beginning to rise from its lowest level, which occurs between 4 and 6 AM.
c) Although the body temperature is rising, it has not reached its peak at this time.
d) Diurnal variations (circadian rhythms) vary throughout the day with the highest body temperature usually occurring between 8 PM and midnight.

Pap smears are recommended as a cancer screening guideline for females aged 13 and older. Pap smears are used to detect abnormal cells in the cervix, which can be an early sign of cervical cancer. Regular screening can help detect cervical cancer at an early stage when it is most treatable. Other options mentioned, such as prostate-specific antigens for men, mammograms for women, and sigmoidoscopies for patients, are not recommended as routine cancer screening guidelines for the general population.

In dark-skinned individuals, the color of the skin may not accurately reflect the presence of cyanosis. Therefore, assessing the lining of the eyelids is a more reliable method to detect cyanosis in these individuals. The lining of the eyelids is usually a lighter shade compared to the surrounding skin, making it easier to identify any bluish discoloration that may indicate cyanosis. This is an important assessment to make, as cyanosis can be a sign of inadequate oxygenation and can indicate a serious underlying health condition.