Nursing 326 Sample Final Exam

To assist in preparation for the final exam please read the following instructions and review the example. The example provides guidance of the detail and thoroughness the exam requires. Please read each question carefully, for example if it asks for five interview questions that is all you need to note, nothing more is required.

The exam will consist of three (3) Case Studies each valued at 100 points. All case studies will ask the same five questions, which require a short written response, which can be in point form (the questions on the exam are the same as used in the example). You may use your textbook to assist in answering the questions but the examination is limited to a completion time of 120 minutes (2 hours).

To see the sample answers, drag your mouse (hold the left button as you move the mouse) between the arrows.

Case Study 1: Assessment of Thorax and Lungs – COPD, Emphysema

You are performing a home visit as a community health nurse on client Mr. Bob. Mr. Bob, aged 65 was discharged two weeks ago from hospital after being hospitalized for ten days with acute respiratory failure due to emphysema, chronic obstructive pulmonary disease (COPD). Mr. Bob has been a smoker for many years, uses oxygen intermittently, and has been hospitalized previously for respiratory failure. Mr. Bob lives alone in a small apartment.

Based on the case study, please provide short answers for the following. Keep your answers centered on the main system or area under investigation
(Case valued at 100 points)

Question 1 - Value: 20 points

Please list five interview questions that would elicit health history information that would be necessary to complete a thorough assessment of this client’s current health concerns.

-> Do you experience difficulty breathing?
Do you have difficulty breathing when you are resting or do any specific activities cause the difficulty?
Do you experience any shortness of breath?
What brings on the shortness of breath, i.e. activity?
How does the shortness of breath affect your work or home activities?
Do you have a cough?
Do you cough up any phlegm or blood?
How would you describe your cough – dry, barking, hoarse, congested, bubbling?
Is the cough related to activity?
What treatments have you tried for your cough?
Does the cough bring on any chest pain?
Do you experience any chest pain with breathing?
Any past history of breathing problems?
Any unusually frequent or severe colds?
Do you smoke cigarettes, cigars or pipe - how much, for how long?
Are there any environmental conditions that may affect your breathing?
What activities do you do that improve your breathing?
What medications are you currently taking, prescription, over the counter, herbal? <-

Question 2 - Value: 25 points

Provide a summary of the physical examination requirements and priorities for the collection of objective data for a thorax and lung assessment, noting the purpose or rationale of each action/procedure and for the chosen sequencing of activities.

1. General Inspection

Client’s facial expression and effort of breathing
Level of consciousness
Skin color and condition
Client’s position
Quality and rate of respirations
Vital signs

2. Inspect the posterior chest

Thoracic cage (shape and configuration of chest wall, anteroposterior diameter related to transverse diameter, neck muscles, position person takes to breathe)

3. Palpate the posterior chest

Confirm symmetric chest expansion during inspiration

4. Tactile fremitus

Access tactile (vocal) fremitus

5. Percuss the posterior chest

Determine the predominant note over the lung fields (resonance, dull)

6. Diaphragmatic excursion

Determine diaphragmatic excursion (percuss the lung border both in inspiration and expiration)

7. Auscultate the posterior chest

Assess breath sounds (diaphragm of stethoscope posterior from apices at C7 to the bases T10 – bronchovesicular, bronchial, vesicular sounds)
Assess adventitious sounds (crackles, wheezes)

8. Inspect the anterior chest

Shape and configuration of chest wall (normal costal angle within 90 degrees

9. Palpate the anterior chest

Palpate symmetric chest expansion
Assess tactile fremitus
Palpate anterior chest wall

10. Percuss anterior chest

Percuss interspaces comparing one side to the other

11. Ausculate the anterior chest

Assess breath sounds (anterior chest from apices in the supraclavicular areas down to the sixth ribs, progress side to side for one full respiration at each location)

Assessment begins with a general inspection, followed by thorax and lung inspection, palpation, percussion and auscultation. <-

Question 3 - Value: 15 points

What objective findings might you expect to find on performing a health assessment on this client (list three possible findings).

Tachypnea, hyperventilation
Shortness of breath
Anteroposterior = tranverse diameter of thoracic cage (barrel chest, costal angle > 90 degrees)
Hypertrophied neck muscles
Tripod position (leaning forward with arms braced on bed or chair)
Use of accessory muscles
Decreased tactile fremitus
Decreased chest expansion
Hyperresonance in the lung fields
Decreased diaphragmatic excursion
Decreased breath sounds
May have wheeze
Bronchophony
Facial expression may be strained, tired
May purse lips in a whistling position
May be drowsy, anxious, restless or irritable due to hypoxia
Clubbing of distal phalanx
May be cyanosis or pallor of skin, lips, nail beds <-

Question 4 - Value: 20 points

Discuss four important patient/client teaching topics, health promotion activities, or cultural considerations that would be appropriate for this client.

Rest frequently
Reduce smoking
Maintain nutrition and hydration
Safety teaching regarding use of oxygen and smoking
Protection against environment pollutants – wear mask, avoid polluted environments
Teach methods to reduce respiratory infections – flu vaccine, avoiding environments where people are ill, hand washing

Question 5 - Value: 20 points

Please provide an example of how you would document the findings of your physical examination and health assessment – base this on typical findings in a client with the noted condition (emphysema).

-> Very individualized marking for this section – short example of some things that may be included:

Recent discharge from hospital for respiratory failure
Vital signs: B/P 134/76, HR 78, R 32, T 37.8 degree Celsius
Tachypnea with respirations regular and unlabored
Face and lips ruddy, nail beds pink, clubbing of finger nails
Barrel chest with intercostal bulging and rigid posture
Diminished breath sounds in lower lobes with discrete, coarse crackles in upper segment of LLL
Client states, has “chronic cough as usual”, difficulty coughing related to decreased energy
Client using oxygen at 3 L/min for approximately 2 hours in the evening after performing activities of daily living <-