Beruflich Dokumente
Kultur Dokumente
Situation: Mrs. Martha Jacobs is a 70-year-old female who tripped at home 2 weeks
ago and suffered a sprain in her right ankle. Her initial treatment included an Ace
bandage wrap, ice, and s nonsteroidal anti-inflammatory drug (NSAID) for discomfort.
She was instructed to elevate the extremities for 3 days and to increase weight-bearing
activity gradually. She is being seen in a follow-up visit and reports that her ankle is
feeling much better, but she has abdominal discomfort.
When question about the problem, she stated, “My stomach has been kind of
achy and it really started a couple of days ago”. She replied to further questioning
saying, “I’ve only had one or two little hard bowel movements in the last five days”.
She denied having problem with bowel elimination in the past and stated, “I usually go
once a day and it’s soft”. In response to further questions she stated that she has been
“essentially, just sitting around, because I’m afraid to put too much weight on my
ankle. I have been eating as usual, but I haven’t been drinking so much because I hate
to have to get up to use the bathroom.”
A physical examination was conducted and the following were found: Bowel
sounds were present in all quadrants, percussion revealed dullness in the LLQ, the
abdomen was softly distended and non-tender, and there were dry feces in the rectum.
Questions:
1. Identify the findings as objective or subjective data.
2. After identifying the assessment data, formulate nursing diagnosis using a two-
part statement nursing diagnosis.
HEALTH ASSESSMENT (CHAPTER 2)
I. Identification
A. Biology
B. Social Environment
C. Physical Environment
________6. It consists of all the things that are experienced through the individual’s
senses and some harmful elements such as radiation, ozone and radon.
________7. It refers to interactions between individuals and others as well as the
institutions in an individual’s community, including churches, schools,
transportations system and protective services.
________8. It includes genetic background, gender, race and ethnicity, family history,
and problems occurring throughout life.
I. Multiple choice
___________1.It follows the oral phase and continues through about 3 years of age.
a. Oral phase b. anal phase c. phallic d. latency
___________2.Adie focuses energy on intellectual and physical pursuits and derives
pleasure from peer and adult relationships and school.
a. Oral phase b. anal phase c. phallic d. latency
___________3.It occurs during the 1st year of life when the mouth is the center of
pleasure.
a. Oral phase b. anal phase c. phallic d. latency
___________4.It covers the period from puberty through adulthood.
a. Oral phase b. anal phase c. phallic d. genitals
___________5. Phase that have a complex known as the Oedipus and Elektra.
a. Oral phase b. anal phase c. phallic d. latency
II. Matching Type
1. Birth to 1 year old a. generativity vs. stagnation
2. 1 to 2 years old b. integrity vs. despair
3. 2 to 6 years old c. intimacy vs. isolation
4. 6 to 12 years old d. identity vs. role confusion
5. 12 to 18 years old e. industry vs. inferiority
6. 19 to 40 years old f. initiative vs. guilt
7. 40 to 65 years old g. autonomy vs. shame and doubt
8. 65 years to death h. trust vs. mistrust
III. Enumeration
14-17. Identify the factors that influence growth and development
18-20. Give three principles of growth and development
• Culture-
• Race-
• Ethnicity-
• Ethnocentrism-
• Diversity-
• Assimilation-
2. Give the factors that affect the cultural aspects in healthcare.
I. Identification
______________________6. The way a person thinks about physical appearance, size and
body functioning.
16-20. Enumerate the 4 external factors that influence the psychosocial health and
define each.
I. Multiple Choice
A. Plexor F. Direct Percussion
C. Fremitus H. Duration
11-20. Enumerate the 5 percussion sounds. Define and write the specific locations of each.
(2 points each)
2. What are the 6 factors that affect the body temperature? Explain each.
3. Identify the routes for measuring the body temperature and give the advantages and
disadvantages of each.
4. Draw a table that indicates the age and the normal respirations per minute.
I. Matching Type
______1) Mild to severe pain A. Acute Pain
______4) Diaphoresis
II.
11-20) Define pain in terms of its duration, origin, location and etiology. (2 points each)
3. Discuss the focus areas described in Healthy People 2010 in relation to nutrition.
4. Identify physical and laboratory parameters utilized in a nutrition assessment.
5. Identify components of a diet history and techniques for gathering diet history data.
1. Identify the anatomy and physiology of the skin, hair, and nails.
3. Explain client preparation for assessment of the skin, hair, and nails.
4. Differentiate normal from abnormal findings in physical assessment.
1. Identify the anatomy and physiology of the structures of the head and neck.
2. Describe the techniques required for assessment of the head and neck.
5. Discuss the focus areas related to the overall health of the head, neck, and related
lymphatics as presented in Healthy People 2010.
______1. A client is recovering from a cardiac catheterization where the right femoral
artery was accessed. Which of the following pulses can the nurse use to assess the
patency of this artery?
______2. The nurse assesses ankle edema in a client. What can the nurse say to the
client about this edema?
______3. The neonatal nurse obtains a newborn’s blood pressure as being 76/40 mm Hg.
Which of the following should the nurse do with this information?
______5. During the assessment of a client’s blood pressure, the nurse notices the client
starting to cry. What should the nurse do?
b. The client has edema. d. The client might have arterial insufficiency.
_____7. A 47-year-old female tells the nurse, “I’m sorry for my hairy legs. I shaved a few
days ago and didn’t have time this morning to do it again.” What does this information
mean to the nurse?
b. The client needs to plan more time for self-care in the morning.
_____8. A client tells the nurse, “My legs really hurt when I walk.” What can the nurse
say to this client in response?
_____9. A 33-year-old female client comes into the clinic with an edematous left calf
that is painful to the touch, feels warm, and is red. Which of the following should be
included in the focused interview of this client?
a. Have you had any facial swelling? c. What medications are you
taking?
b. Are you experiencing any emotional upset? d. How long have you had varicose
veins?
______10. The nurse wants to further assess a client’s radial pulse. What can be done to
do this assessment?
______11. A client’s blood pressure is 158/90 mm Hg. What does this reading suggest to
the nurse?
______12. A client’s fingertips are large and very round. How can this data be
documented?
______13. A client tells the nurse she has calf pain. Which of the following should the
nurse do?
b. Walk with the client and ask her to rate the pain.
______14. A 68-year-old client has lower extremity edema and thick skin discolored to a
dark brown. The client complains of his legs “feeling full.” Which of the following does
this information suggest to the nurse?
______15. Using the Healthy People 2010 recommendations for blood pressure and
stroke, the nurse wants to include actions for both of these conditions in the next staff
inservice. Which of the following actions would be appropriate for both of these
conditions?
a. Warning signs
b. Annual blood pressure screening
c. Exercise
d. Smoking cessation
______1. A client tells the nurse, “I have a stomachache almost every day.” Which of the
following could the nurse respond to this client?
______2. The nurse learns a client takes more than three times the recommended
amount of an over the counter pain reliever on a daily basis and is concerned about his
liver. What is the reason for this concern?
______3. The nurse is preparing to examine a client’s abdomen. Which of the following
landmarks could be considered a thoracic structure?
______4. The nurse wants to assess bowel sounds on a client with abdominal pain.
Where would the nurse hear those sounds the best coming from the stomach?
a. RUQ c. LLQ
b. RLQ d. LUQ
______5. The nurse is planning to palpate a client’s bladder. Which area of the abdomen
should this palpation be done?
______6. The mother of an 18-month-old child tells the nurse, “I can see his belly
rumbling. Is this normal?” Which of the following can the nurse respond to this client?
c. There is a good pediatric gastroenterologist that I know who can help you.
d. The muscles of the abdomen are thin in babies. So you will see this.
______7. The 79-year-old female tells the nurse, “I don’t drink as much water as I should
because it makes me have to go to the bathroom.” What is this client prone to
developing?
b. Diarrhea d. Hemorrhoids
______8. An overweight client tells the nurse, “I was raised to eat everything on my
plate.” What can the nurse say to help with this client’s weight problem?
a. There are some small changes that you can make to help with your weight problem.
b. I was raised the same way.
______9. After inspecting a client’s abdomen, which assessment technique should the
nurse use next?
a. Percussion c. Palpation
______10. A client comes to the hospital with nausea, vomiting, and ongoing sciatic
pain. Which of the following should be included in the focus interview with this client?
______11. A client tells the nurse, “I get stomach burning when I drink wine.” Of what is
this information an indication?
______12. The client tells the nurse, “I’ve had diarrhea ever since my mother was
admitted to the hospital with a heart attack.” What can the nurse say to the client
about this information?
______13. After assessing a client, the nurse writes “striae present bilateral costal
margins.” What should the nurse do with this information?
______15. A 70-year-old male client comes into the clinic with weight loss and difficulty
swallowing. Which of the following should the nurse document for this client?
a. Dysphagia
b. Aphasia
c. Odynophagia
d. Bulimia
______1. A client has been diagnosed with a kidney stone, lodged within the medulla of
the right kidney. Which of the following will this stone most effect?
______2. During the abdominal assessment of a male client, the nurse palpates large
round mass in the hypogastric region. Which of the following could explain what this
nurse has palpated?
a. The client has a tumor in his small intestines. c. The client has a distended or
full bladder.
______3. During the assessment of a client’s urinary system, the nurse finds a location
on the client’s back. What landmark is this?
______4. A client three weeks postpartum comes into the clinic with the complaints of
urinary frequency and burning with urination. Which of the following can the nurse
explain to this client about these symptoms?
d. After having a baby, your bladder has less sensation and you could get an infection.
______5. A client says to the nurse, “I wish I could have a complete night’s sleep without
having to get up every two hours to go to the bathroom.” The nurse realizes this client
is experiencing:
b. Nocturia d. Oliguria
______6. A client with urinary incontinence tells the nurse, “I haven’t been to the senior
center for weeks.” Which of the following would be an appropriate response for the
nurse to make to this client?
c. Can you tell me why you haven’t gone to the senior center?
______7. A 68-year-old female tells the nurse, “Since the hysterectomy, I can’t seem to
hold my water.” Which of the following can the nurse explain to this client?
______8. A client asks the nurse, “What does having diabetes have to do with
urinating?” Which of the following would be an appropriate response to make to this
client?
a. You are asking too many questions. c. Diabetes can hurt the kidneys.
______9. A client with long-standing renal disease comes into the clinic with the
complaint of “itchiness.” The nurse realizes this as being:
______10. The mother of a two-year-old child tells the nurse that the baby was born
deaf. Which of the following should the nurse do at this time?
a. Assess how well the baby sleeps. c. Assess the baby’s appetite.
b. Assess the mother’s level of rest. d. Assess the baby’s urine output.
______11. The nurse wants to assess the renal arteries. Where should the stethoscope
be placed to do this assessment?
a. Costovertebral angle
b. Epigstric region
d. Hypogastric region
______12. A client comes into the clinic with excruciating pain in his scrotum. Which of
the following should the nurse do?
______13. During the assessment of a client’s kidneys, the nurse is unable to palpate
the organs from the back of the client. What does this finding suggest to the nurse?
a. The client’s kidneys are misplaced.
______14. A 79-year-old client on pain medication for spinal stenosis tells the nurse,
“Now I can’t make it to the bathroom and I’m wetting myself while I sleep.” The nurse
realizes this client is describing:
a. Functional incontinence
b. Urge incontinence
c. Total incontinence
d. Reflex incontinence
______15. The mother of a four-year-old male child tells the nurse, “I can’t believe he’s
still wetting the bed.” Which of the following can the nurse instruct this mother?
c. Wait for a few more months and see if stops. Let us know if it doesn’t.
d. Wait for a few more months and see if stops. Let us know if it doesn’t.
______1. A 16-year-old male client tells the nurse, “I’m worried because I think I have
misshaped private parts.” Upon examination, the nurse learns the client is concerned
about his scrotum. Which of the following can the nurse explain to this client?
b. You are right. I think you should talk with the doctor.
______2. A 32–male-client has been diagnosed with an infection of his epididymis. Which
of the following would be appropriate for the nurse to instruct this client?
b. This is unusual.
______4. The mother of a two-month-old male infant says to the nurse, “I think there’s
something wrong. His scrotum looks so big.” Which of the following can the nurse say
in response to this mother?
______5. A 48-year-old male tells the nurse, “I have a good wife, but I’m just not
interested in sex anymore.” Which of the following would be appropriate for the nurse
to respond?
______6. The father of a 15-year-old male adolescent is concerned because he heard his
son “was touching another boy’s private parts in the shower at school.” Which of the
following can the nurse respond to this father?
a. Has he said anything to you about it?
c. He might be homosexual.
______7. The nurse with a history of sexual abuse has difficulty in assessing clients’ sex-
related organs. Which of the following can be done to support this nurse’s discomfort?
b. Assist this nurse to find ways to work through her own feelings.
______8. A male client tells the nurse that he is concerned because his wife hasn’t been
able to get pregnant even though they’ve been trying for six months. What should the
nurse say in response to this client?
______9. A male client says to the nurse, “I’m so embarrassed. When I’m erect, my
penis isn’t straight. Is there some kind of surgery to fix this or something?” What can
the nurse respond to this client?
______11. The nurse is having difficulty during the focused interview of an adolescent
male’s sexual activity. Which of the following should the nurse do at this time?
______12. During the inspection of a male client’s genitalia, the nurse notes a white
cheesy substance on the glans penis. What should the nurse document about this
finding?
a. Smegma present
______13. During the physical examination of a male client’s scrotum, the nurse
palpates a mass. What should the nurse do next with this information?
b. Ask the client how long he’s had a tumor in his testicle.
______14. During the assessment of a client’s prostate gland, the nurse notes multiple
varicose veins around the anal opening. Which of the following should be done with this
information?
c. Note the characteristics of the varicosities and proceed with the exam.
______15. A 51-year-old male has never had a prostate examination. Which of the
following should be done for this client?
d. Nothing.
______1. Prior to the client having a gynecological examination, the client says, “How
can you see my uterus this way?” An appropriate response for the nurse to make would
be:
______2. A woman in her third trimester of pregnancy tells the emergency room nurse,
“I was okay and then I had a big wad of bloody mucus come out of me and horrible
pain.” The nurse realizes this client is describing:
______3. A 38-year-old female client tells the nurse, “I have no interest in sexual activity
since my husband died last year.” Which of the following does the nurse realize this
client is demonstrating?
a. Feelings of betrayal
______4. During the focused interview, the nurse learns that a client had the onset of
menarche at age 10. Which of the following can the nurse surmise from this
information?
c. This is late.
d. This is normal.
______5. A client tells the nurse, “I had an abortion years ago,” and proceeds to cry.
Which of the following should the nurse do to support this client?
b. Offer a tissue.
c. Ask how the client has she been emotionally since the abortion.
a. A yeast infection
b. Contact dermatitis
d. A herpes infection
______7. The nurse learns that a client does not perform self-examination of her
genitalia. What can the nurse do to instruct this client?
a. Instruct in the ways to conduct this examination and the reasons why it should be
done monthly.
c. Suggest she make a monthly appointment at the clinic for the nurse to examine this
area.
______8. A 45-year-old female tells the nurse, “Confidentially, I’ve never had an orgasm
with a man.” Which of the following should the nurse respond to this client?
______9. During the focused interview, the nurse learns that a postmenopausal client
has “pain with sex” and is “hot almost all of the time.” Which of the following is this
client describing?
b. Sexual arousal
c. Sexual inhibition
______10. A college student comes into the clinic to be “checked” because she recently
“wasn’t careful” and is fearful of pregnancy. Which of the following should the nurse
respond to this client?
a. Were you date raped?
______11. After the examination of a client, the nurse writes “labia majora symmetrical
and smooth, without lesions.” Which of the following does this information imply?
______13. During the palpation of a client’s vaginal walls, the nurse feels a bulging
along the posterior wall. This finding suggests to the nurse:
a. A prolapsed uterus
b. A cystocele
c. A rectocele
1. What are the 12 cranial nerves? Give its function and corresponding activity.
2. Explain the following problems related to motor function.
• Ataxic Gait
• Scissors Gait
• Steppage Gait
• Festination Gait
• Fasciculation
• Tic
• Tremor
• Athetoid Movement
• Dystonia
• Myoclonus
• First trimester
I. ASSESSMENT
II. DIAGNOSIS
IV. EVALUATION
INSTRUCTION: Identify the cranial nerves involve when these disruption of function
results is present.
______________ 1. Inability to move eye upward or temporally
______________ 2. Inability to move eye down or nasally
______________ 3. Inability to move eye temporally
______________ 4. Inability to move eye upward temporally
______________ 5. Inability to move eye down ward or temporally
______________ 6. Inability to move eye nasally
Matching type: Identify the eye abnormalities; write the letter of your choice in the
blank before the number.
6. Epistaxis is a nosebleed T F
9. Nasal polyps are pale, round, firm, non-painful overgrowth of nasal mucosa T
F
10. Sight in growth of the lower nasal septum is called Deviated Septum
T F
II ABNORMAL FINDINGS:
A.TACHYPNEA
Slow, regular respirations,
Rate>24
Precipitating factors:
fever,fear,exercise,pneumonia,pleuritic
pain,alkalosis
B.BRADYPNEA
Slow,regular respiration,
Rate<10
Precipitating factors: diabetic, coma, drug-
induced respirator depression, increased
Intracranial pressure
C.HYPERVENTILLATION
Irregular, shallow respiration,
Rate>24
Precipitating factors: extreme exertion,
fear, diabetic ketoacidosis
(kussmauls),hypoxia, Hypoglycemia
D.HYPOVENTILLATION
Irregular, shallow respiration
Rate<10
Precipitating factors: narcotic overdose,
anesthetics, prolong bed rest, chest
eplenting
E.CHEYNE-STOKES
Periods of deep breathing alternating with
periods of apnea, regular pattern
Precipitating factors: normal children and
aging, heart failure, uremia, brain
damage, drug-induced respiratory
depression
F.BIOT’S (Ataxic) Respirations
Shallow, deep respirations with periods of
apnea,
Irregular pattern
Precipitating factors: respiratory
depression, brain damage
G.SIGHING
Frequent sighs
Precipitating factors: hyperventilation
syndrome, nervousness. Causes: dyspnea,
dizziness
H.OBSTRUCTIVE BREATHING
Prolong expiration
Precipitating factors: COPD, asthma,
chronic bronchitis
HEALTH ASSESSMENT (CHAPTER 16)
1. Teach the client to observe her breast in front of a mirror and in good lighting. Tell
her to observe her breast in four positions.
a. With her arms relaxed and at her sides.
b. With her arms lifted over her head.
c. With her hands pressed against her hips
d. With her hands pressed together at the waist, leaning forward.
Instruct her to look at each breast individually, and then to compare them. She
should observe for any visible abnormalities, such as lumps, dimpling, deviation,
recent nipple retraction, irregular shape, edema, discharge or asymmetry.
2. Teach the client to palpate breast while standing or sitting with one hand behind her
head. Tell her that many women palpate their breast in shower because water and
soap make the skin slippery and easier to palpate all areas of her breast, using the
concentric circles technique. Tell her to press the breast tissue gently against the
chest wall and to be sure to palpate the axillary tail.
3. Instruct the client to palpate her breast again while lying down, as described in step
2. Suggest that she place a folded towel under the shoulder and back on the side to
be palpated. The arm on the examining side should be over her head, with her hand
under the head.
4. Teach the client to palpate the areolae and nipples next. Show her to compress the
nipple to check for discharge.
5. Remind the client to use a calendar to keep a record of when she performs SBE.
Teach her to perform SBE at the same time each month, usually 5 days after the
onset of menses, when there is less hormonal influence on tissues.
6. Remind clients who are post menopausal to continue monthly SBE. They should
perform the exam at the same time each month.
Identification:
By:
Odette Macarubbo, RN (Chapter 1-4)
Ma. Jessica Ahorro, RN (Chapter 5-8)
Melody Gatdula, RN (Chapter 9-12)
Zenaida Evangelista, RN (Chapter 13-17)
Don Xavier Gancia, RN (Chapter 18-22)
Lhorlit Dela Pena, RN (Chapter 23-27)