Nursing 104

N104 Study Guide

Chapter 2 1. B - This is the definition of the standard anatomical position. 2. A - Begin an assessment from the least intrusive and progress through to the most intrusive technique. Palpation may cause other pieces of the assessment to be inaccurate if conducted early in the exam. 3. D - Dark skinned individuals will often have palms that are shades lighter than the rest of their skin. 4. C - The pupils should be black, equal in size at 3-7 mm. 5. C - The healthy tympanic membrane is shiny and pearly gray in color. Cerumen, or earwax, should be seen in the healthy ear. Excessive cerumen is a deviation from normal. To examine the ear, the largest speculum should be used that does not cause discomfort to the patient. 6. A - Receding gums are a sign of periodontal disease. Many adults will have less than 32 teeth if they have had planned dental extractions. The gums should be pink and firm. Tooth enamel will range in color but should not be black or brown. 7. D - Vesicular and bronchovesicular breath sounds are normal. 8. A - The S3 gallop is not a normal finding in the older adult patient and should be documented. 9. B - The color should return to the nail bed in less than one second. The patient may experience momentary minor discomfort when the nail bed is compressed. 10. C - Following abdominal surgery, the patient may not have normal bowel sounds due to the manipulation of the bowels during surgery. Although absent or hypoactive bowel sounds is not a normal finding, it is expected immediately after abdominal surgery. The astute nurse will perform frequent assessment of bowel sounds until active sounds return.

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