ATI NR 304 Final Exam Review ( whole book in summed up for exam)

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1. Cranial nerve 3= oculomotor nerve, responsible for eye movement and pupillary response to light; if it’s functioning properly, expected reaction is pupil constriction in response to light 2. K... now pulses: posterior tibial***, pedal pulse, femoral, know where they are (there will be a diagram…***HINT HINT KNOW WHERE POSTERIOR TIBIAL PULSE IS**** 3. Radial pulse is irregular, assess apical pulse for a full minute!! 4. Objective vs. subjective data 5. Some complications due to immobility: contractures of extremity, crackles in the lungs, pressure ulcers (especially on bony prominences) 6. Voiding small amount of urine less than 100mL frequently (which is 2-3 times an hour) and dribbling of urine are manifestations of urinary retention 7. Auscultate abdomen PRIOR to palpating to prevent altering bowl sounds 8. Self-reporting pain scale, even if patient can’t communicate, they’ll report to you in some way via expressive aphasia (even if they had CVA they’ll let you know if they’re in pain) 9. McBurney’s point for suspected appendicitis, located midway between naval to right iliac crest, press down in lower right quadrant (that’s the area) 10. Diverticulitis assess in lower left quadrant (found in sigmoid colon) 11. If pt has dehydration, they will have poor skin turgor or tenting present (over sternum, back of hand, upper shoulder, back) 12. Pt with cast on, feel warmth on the cast, and painful, indicated infection 13. If pt has increased intracranial pressure, and demonstrates decorticate posturing, plantar flexion of legs is an indicator of decorticate posturing 14. Risk factors for osteoporosis sedentary lifestyle (modifiable) 15. Chronic venous insufficiency increased in venous hydrostatic pressure which develops when fluid accumulates in veins which causes fluid to leak out into the tissues which results in EDEMA 16. RN priority in recover room: airway, oxygen 17. Pt has BPH, they have urinary retention, may feel pressure, distended bladder, tendinous over symphysis pubis, frequent voiding 18. Self-breast examinations CAN be performed in the shower 19. Growth spurts and height for boys occur towards the end of mid-puberty, boys can grow an average of 4-12 inches during this period 20. Teaching about testicular cancer, close male relatives are at an increased risk, typically occurs between ages of 15-35 years 21. Symptoms of bacterial vaginosis gray, white discharge with fishy odor 22. Pt who has right sided acoustic neuroma affects cranial nerves 9 & 10 (glossopharyngeal and vagus nerves), affects muscles of soft palate, larynx, and pharynx; impairment of these nerves places client at risk for aspiration so make sure SUCTION WORKS properly/you have access to it 23. Child has moro reflex, should disappear between 3-4 months of age This study source was downloaded by 100000803505854 from CourseHero.com on 06-07-2021 13:34:29 GMT -05:00 https://www.coursehero.com/file/37417859/NR-304-Final-Examdocx/ This study resource was shared via CourseHero. [Show More]

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