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Nursing 280 > Exam 2 > Flashcards

Exam 2 Flashcards

1
Q

Review of Systems (ROS)

A

Systematic method for collecting data on all body systems

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2
Q

Assessment Techniques

A 
Inspection
Palpation
Percussion
Auscultation
Olfaction
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3
Q

Back of hand

A

sensitive to temperature variations

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4
Q

Pads of finger

A

subtle changes in texture, shape, size, consistency, and pulsation

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5
Q

Palm of hand

A

vibration

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6
Q

Auscultation

A

Listening to sounds produced by the body with a stethoscope

diaphragm for high pitch sounds

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7
Q

Skin color variations with Anemia

A

Loss of pigmentation

Patchy area on skin over face, hands, arms

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8
Q

yellow-orange skin color

A

Sclera, mucous membranes, skin
Increased deposit of bilirubin in tissues
indicates liver disease, destruction of red blood cells

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9
Q

Red skin color

A

Face, area of trauma, sacrum, shoulders
Increased visibility of oxyhemoglobin caused by dilation or increased blood flow
Fever, trauma, blushing, alcohol intake

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10
Q

Macule

A

Flat, nonpalpable change in skin color, smaller than 1 cm

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11
Q

Papule

A

Palpable, circumscribed, solid elevation in skin, smaller than 0.5 cm

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12
Q

Nodule

A

Elevated solid mass, deeper and firmer than papule, 0.5-0.2 cm

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13
Q

Tumor

A

Solid mass that may extend deep through subcutaneous tissue, larger than 1-2 cm

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14
Q

Wheal

A

Irregularly shaped, elevated area or superficial localized edema, varies in size

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15
Q

Vesicle

A

Circumscribed elevation of skin, filled with serous fluid, smaller than 0.5 cm

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16
Q

Varicella (shingles)

A

Seen in elderly, immune-compromised
Avoid contact if not had chicken pox
Painful

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17
Q

Pustule

A

Circumscribed elevation of skin similar to vesicle but filled with pus, varies in size

18
Q

Ulcer

A

Deep loss of skin surface that may extend to dermis and frequently bleeds and scars, varies in size

19
Q

Atrophy

A

Thinning of skin with loss of normal skin furrow, with skin appearing shiny and translucent, varies in size

20
Q

Neurological assessment

A

Often is assessed as you perform your physical exam
Does patient follow simple and complex commands
Movement: assess as you perform hygiene, help ambulate, assist to toilet

21
Q

Thought Process

A

This is a description of the way in which they think

22
Q

Thought Content

A

A description of what the patient is thinking about

23
Q

1+ edema

A

Mild pitting, slight indentation, no perceptible swelling of the leg

24
Q

2+ edema

A

Moderate pitting, indentation subsides rapidly

25
Q

3+ edema

A

Deep pitting, indentation remains for a short time, leg looks swollen

26
Q

4+ edema

A

Very deep pitting, indentation lasts a long time, leg is very swollen

27
Q

S1

A

Closure of mitral & tricuspid valves
Signals the beginning of systole
Loudest at apex

28
Q

S2

A

Closure of aortic & pulmonic valves

Loudest at the base

29
Q

Jugular Venous Pressure

A

Reflect filling pressures & volume changes in right side of heart
Evaluate with patient at 45-degree angle

30
Q

Pulse rating

A 
0  - Absent
 1+ - Palpable but weak 
 2+ - Normal 
 3+ - Increased 
 4+ - Bounding 
D = Doppler
31
Q

Nursing process

A 
Assessment
Nursing diagnosis
planning
implementation
evaluation
32
Q

Types of diagnoses

A

Actual
Potential (Risk for)
Wellness (Readiness for)
Syndrome (6 in NANDA)

33
Q

Parts of the nursing diagnoses

A 
Diagnostic Label (Problem)
Related factors (Etiology) 
Defining characteristics (S+S)
34
Q

Ethnocentrism

A

superiority of a cultural, ethnic, or professional group

35
Q

Xenophobia

A

morbid fear of strangers

36
Q

Cultural Competence

A

set of cultural behaviors and attitudes integrated into the practice methods of a system, agency, or its professionals, that enables them to work effectively in cross cultural situations

37
Q

Direct communication

A

focuses on explicit meaning of words and dealing directly with conflict

38
Q

Indirect communication

A

not everything needs to be said, but can be implied

39
Q

Formal communication

A

emphasis on good manners, use of titles and honorifics and in general supports social hierarchical structures

40
Q

Informal communication

A

emphasizes being courteous in a casual manner, by use of first names on first acquaintances

41
Q

Cultural competence model (ASKED)

A 
Awareness (personal biases)
Skill
Knowledge
Encounters (how many encounters have you had)
Desire

Nursing 280 (3 decks)

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