Exam 1 Main Points Flashcards
(198 cards)
1
Q
validation of data entails
A. distinguishing normal from abnormal
B. making inferences
C. using an organized and comprehensive approach
D. checking the accuracy and reliability of the data
A
D
2
Q
which critical thinking skill helps the nurse to see relationships among the data
A. validation
B. clustering related cues
C. identifying gaps in the data
D. distinguishing relevant from irrelevant
A
B
3
Q
an example of subjective data is
A. decreased range of motion
B. crepitation in the left knee joint
C left knee has been swollen and hot for the past 3 days
D. Arthritis
A
C
4
Q
which of the following is considered an example of objective data
A. Alert and oritented
B. dizziness
C. an ear ache
D. A sore throat
A
A
5
Q
what priority would a BP 60/40
A
first
6
Q
what priority would breathing difficulty and a pulse ox reading 88 on room air
A
first
7
Q
what priority would hunger and thirst be
A
third
8
Q
what priority would anxiety be
A
second
9
Q
what priority would a temp of 103 be
A
second
10
Q
data collection
A
collection of data about an individuals health state
11
Q
assessment purpose
A
make judgment/diagnosis
12
Q
subjective data
A
what a patient tells you
13
Q
objective data
A
measurable, observations
14
Q
what part of the nursing process would objective and subjective data fit in
A
assessment
15
Q
what makes up the data base
A
subjective
objective
records
lab studies
16
Q
3 dimensions on critical thinking
A
theory and experiental knowledge to preform the nursing process
commitment to learn to think critically
psychomotor and manual skill development
17
Q
nursing process
A
assessment
diagnosis
planning
implementation
evaluation
18
Q
assessment
A
ability to gather data that is
- accurate
- relevant
- organized
- systematic
- complete
- and differentiates normal and abnormal
19
Q
diagnosis
A
as a nurse we cluster cues and based on those what nursing actions we are going to make
20
Q
planning
A
what we want to happen
~goals
21
Q
implementation
A
things we add/take away to reach a goal
22
Q
evaulation
A
did we reach the goal
23
Q
first level priorities
A
airway
breathing
circulation
24
Q
2nd level priorities
A
acute pain
change in mental status
infection
25
3rd level priorities
lack of knowledge
Family coping
activity
rest
26
complete total health data base
describes current and past health state and forms a baseline to measure all future changes
27
episodic/problem centered database
collect mini database, smaller scope and more focused than complete
28
follow up data base
status of all identified problems should be evaluated at all regular and appropriate intervals
29
emergency data base
rapid collection of data often compiled concurrently with life saving measures
30
what is EBP
use of evidence based research implemented at the clinical level to ensure best patient outcomes
31
3 points to EBP
integration of research evidence
clinical expertise/knowledge
patient values and preferences
32
what is a general survey
looking/inspecting at the general state of health and obvious physical characteristics of a person
33
what is the normal amount of pain
depends on the patient
34
dysarthria
difficulty speaking caused by brain damage which results in inability to control muscles used in speech
35
dysphonia
diffuculty speaking due to physical disorder of the mouth, tongue or vocal cords
36
aphasia
loss of ability to understand or express speech caused by brain damage
37
4 components of general survey
physical appearance
body structure
mobility
behavior
38
physical appearance
age
sex
level or consciousness
skin color
facial features
39
body stature
stature
nutrition
symmetry
posture
position
body build/contor
40
mobility
gait
range of motion
41
behavior
facial expression
mood and affect
speech
dress
personal hygiene
42
normal temp range
35.8-37.3
43
normal stroke volume
70mL
44
pulse is a pressure wave created by
stroke volume
45
force of pulse scale
0-3
46
pulse force 1
weak/thready
47
pulse foce 2
normal
48
pulse force 3
bounding
49
what to document when taking pulse
site
rate
force
rhythm
50
what do you do if you can't palpate the pulse
use a doppler
51
1 breath consists of
1 inspiration and 1 expiration
52
Respiratory rate
10-20
53
normal pulse ox rate
97-100
54
systolic
maximum pressure felt on the artery during left ventricle contraction
55
diastolic
pressure against the vessel between contractions
56
what lasts longer diastole or systole
diastole
57
pulse pressure
difference between systolic and diastolic blood pressure
58
orthostatic hypotension drop in systolic of
20
59
orthostatic hypotension increase in
pulse >20
60
why would there be an increase in orthostatic hypotension in elderly
due to vascular changes with aging
61
common errors with blood pressure assessment
arm placement
patients hold arm up
legs are crossed
examiner eyes not level with manometer or meniscus
incorrect cuff size
failure to palpate for level of inflation
deflate too fast or too slow
stopping during descent and then reinflating
failure to wait 1-2 mins between readings
subconscious bias
diminished hearing ability of exmainer
defective equipment
number preferences
62
korotkoff 1
systolic
63
korotkoff 5
diastolic
64
which patient would be most likely to present with a pulse rate that is lower than normal
A. 70 year old telephone salesman presenting dehydration
B. 20 year old runner who had surgery for a fractured leg
C. 67 year old who presented with an exacerbation of his COPD
B
65
common errors in blood pressure measurement include
A. taking blood pressure in an arm that is at the level of the heart
B. waiting <1-2 mins before repeating the blood pressure reading in the same arm
C. waiting 30 mins if the client has just smoked a cigarette
D. using a blood pressure cuff whose bladder is 80% of the arm circumference
B. we want to wait at least 1-2 (>1-2)
66
order for assessment
inspection, palpation, percussion, auscultation
67
inspection
careful thorough observation
68
do we listen over clothes
no
69
palpation uses the sense of
touch
70
can we determine the disease state by palpating
no
71
light palpation
use to detect surface characteristics
72
deep palpation
use intermittent pressure to examine abdominal contents
73
fingertips are used for
fine discrimination such as texture, swelling, pulsation, presence of lumps
74
grasping action are used for
detect shape, size, position, consistency of an organ
75
base of fingers are used for
detect vibration
76
dorsum of hands are used for
temp changes
77
bimanual palpation
compare both sides
78
if the patient states they have pain should we palpate that first or last
last
79
always begin with light or deep palpation
light
80
percussion
tapping the skin with short, sharp stokes that produce a vibration to assess underlying structures
81
structures with air will produce
louder, longer, deeper sound because it can vibrate freely
82
denser more solid structures produce
softer, higher, shorter, sound because they can't vibrate as easily
83
resonant
over lung fields, sound clear, hollow
84
tympany
over abdomen sounds drum like
85
dull
over organs sounds like a muffled thud
86
flat
over bone, muscle, tumor, sound comes to a dead stop
87
diaphragm
high pitched sounds
88
bell
detect low pitched sounds
89
preform exam from the _______ side of the patient
right
90
the bell of the stethoscope
A. is used for soft, low pitched sounds
B. is used for high pitched sounds
C. is held firmly against the skin
D. magnifies sounds
A
91
what is the correct order for assessment
inspection
palpation
percussion
auscultation
92
_______________ can affect mental status
electrolytes
93
components of a mental status exam
appearance
behavior
cognition
thought processes and perception
94
appearance
body movements
dress
grooming
hygiene
95
behavior
level of consciousness
facial expression
speech
mood and affect
96
cognitive functioning
oritentation
attention span
recent memory
remote memory
new learning
97
thought processes
thought content
perceptions
suicidal thoughts
98
multiple cognitive deficits
(dementia/delirium)
dementia
99
may develop in addition to diseases during period of hospitalization
(dementia/delirium)
delirium
100
acute disturbance of consciousness and cognition
(dementia/delirium)
delirium
101
chronic disturbance of consciousness and cognition
(dementia/delirium)
dementia
102
medical conditions preclude this condition
(dementia/delirium)
delirium
103
long and short term memory loss with short term more pronounced
(dementia/delirium)
dementia
104
affects speech and language
(dementia/delirium)
dementia
105
you have a patient that comes in with multiple cognitive deficits and a chronic disturbance of consciousness and cognition with speech and language issues
dementia
106
is dementia reversible
no irrereversible
107
is delirium reversible
yes
108
levels of consciousness
alert
lethargic
obtubnded
stupor/semi coma
coma
109
alert
Awake or readily aroused; oriented, fully aware of external and internal stimuli and responds appropriately; conducts meaningful interpersonal interactions.
110
lethargic
Not fully alert; drifts off to sleep when not stimulated; can be aroused to name when called in normal voice but looks drowsy; responds appropriately to questions or commands but thinking seems slow and fuzzy; inattentive; loses train of thought; spontaneous movements are decreased.
111
obtunded
Sleeps most of time; difficult to arouse—needs loud shout or vigorous shake; acts confused when is aroused; converses in monosyllables; speech may be mumbled and incoherent; requires constant stimulation for even marginal cooperation.
112
stupor/semi coma
Spontaneously unconscious; responds only to persistent and vigorous shake or pain; has appropriate motor response (i.e., withdraws hand to avoid pain); otherwise can only groan, mumble, or move restlessly; reflex activity persists.
113
coma
Completely unconscious; no response to pain or any external or internal stimuli (e.g., when suctioned, does not try to push the catheter away); light coma has some reflex activity but no purposeful movement; deep coma has no motor response.
114
sedation scale
S-4
115
sedation scale S
asleep, easy to arouse
116
sedation scale 1
awake and alert
117
sedation scale 2
slightly drowsy, easily aroused
118
sedation scale 3
frequently drowsy, arousable, drifts off to sleep during conversation
119
sedation scale 4
somnolent, minimal or no response to physical stimulation
120
glasgow coma scale measures
motor, verbal, eye response
121
Glasgow coma scale what number determines coma
8
122
broca AKA
expressive aphasia
123
wernicke AKA
receptive aphasia
124
what aphasia type is most common and severe
global
125
global aphasia is caused by
large lesion that affects anterior and posterior language areas
126
how would someone with global apahsia present
speech is absent or only a few words
no compresension
can't respect, write or read
127
brocas/expressive is caused by
lesion in the motor cortex of the anterior portion of the brain
128
can people with broca/expressive hear and read
yes
auditory and reading comprehension are intact
129
how would someone with brocas/expressive present
able to understand
can't express self using language
can't respect or read aloud
130
wernicke/receptive is caused by
lesion in the posterior area of language center
131
how would a patient present with wernicke/receptive
can hear sounds but can't relate to them
speach is fluent
patient had great urge to speak
words are made up and frequented
incomprehensible speech
impaired repetition, reading and writing
132
how do you communicate with broca/expressive
speak clearly
books on tape
picture board
written words
yes/no questions
email
133
how can you communicate with wernicke/receptive
picture board
don't keep talking and repeating
don't write, can't read
use gestures to help with understanding
134
a major characteristic of dementia is
A. impairment of short and long term memory
B. hallucinations
C. sudden onset of symptoms
D. substance induced
A.
135
pain is subjective or objective
subjective
136
what are some examples of holistic pain relief
music, relaxation, massage, biofeedback, acupuncture
tubes to decompress/relieve pressure
anxiolytics
improving breathing and oxygenation
positioning
heat and/or cold application
137
4 concepts or nociception
transduction
transmission
perception
modulation
138
transduction
stimulus takes place in periphery
139
transmission
pain moves from spinal cord to brain
140
perception
conscious awareness of pain sensation
141
modulation
inhibition or pain sensation
142
when we treat pain we take 4 basic approaches toward each of these 4 components within the neuroatomic pathway
1. we can modify the source of pain
2. we can attempt to alter the central perception or pain
3. we can modulate the transmission or pain in the CNS
4. we can block the transmission of pain to the CNS
143
how do we modify the source of pain (transduction)
general anesthetic
anti inflamatory
144
how do we modify the movement of painful stimuli (transmission)
narcotics
opioids
145
how do we modify the awareness of pain (perception)
distractions
exercise
music
acupuncture
146
how do we inhibit the pain (modulation)
Pharmaceutical
147
neuropathic pain is normal or abnormal
abnormal
148
does neuropathic pain follow the predictable phases of nociceptive pain
no
149
what pain is the most difficult pain to assess and treat
neuropathic
150
neuropathic pain is perceive
long after injury heals
151
visceral pain
organ pain
152
deep somatic pain
tendon, blood vessles
153
cutaneous pain
skin pain, superficial
154
referred pain
felt at a particular site but originates in another location
155
acute pain
short term
self limiting
follows a predictable trajectory
dissipates after injury heals
has a protective quality
activates autonomic nervous system
vital sign indication
malignant pain
156
chronic pain
continues beyond the expected time
malignant and nonmalignant pain
does not stop when injury heals
has no protective qualities
the level of pain may not correspond with physical findings
could have increased tolerance
157
acute pain signs and symptoms
protective
diaphoresis
anxiety
restless/stillness
moaning
158
chronic pain signs and symptoms
normal vital signs
skin warm and dry
depressed
anxiety
anger/irritability
substance abuse
no protective behavior
bracing, rubbing
sighing
appetite change
reduced activity
159
is pain a normal process of aging
no
160
pain assessment questions
where is your pain
when did it start
what does your pain feel like
how much pain do you have now
what makes it better or worse
how does it limit your activities
how do you behave when in pain
what does you pain mean to you
why do you think you are having pain
161
PQRST
provoke
quality
radiates
severity
time
162
2 types of pain rating scales
numeric
descriptor
163
what do elderly think about pain and treatment
no pain medication because of addiction
164
which type of pain would cause cholecystitis
A. somatic
B. visceral
C. cutaneous
D. chronic
B. visceral
165
what anticipated finding regarding patients with chronic pain should guide a nurses care planning
A. patients with chronic pain have trouble sleeping
B. patient with chronic pain show elevated blood pressure
C. patients with chronic pain need less medications
D. patients with chronic pain may show few or no outward signs of pain
D
166
T/F
you have to have physical signs for pain to exist
false
167
T/F
self report is the most accurate indicator of pain
true
168
T/F
prolonged use of narcotics pain medications leads to addiction
false
169
T/F
older adults ahem decreased pain sensations
false
170
a confused elderly patient with dementia with a broke hip
what pain scale
descriptive
171
a 20 year old who just had four wisdom teeth extracted
what pain scale
numeric
172
a 50 year old person with chronic rheumatoid arthritis
what pain scale
numeric
173
aging skin
drier, flatter skin
decrease sebum and sweat production
decrease elasticity
decreased number of functioning melanocytes
decrease elastin, collagen, subq fat
change in temp regulation
changes in nail
174
are older adults more or less at risk for pressure injuries
more at risk due to changes in circulation and decreased ability to form new collagen
175
unstageable pressure wound
covered, not able to see depth, needs to be debrided
176
who might be able to have an inability to sense temp, friction
diabetic patients
177
warfarin does what to blood vessels
makes them more fragile
178
braden scale categories
sensory preception
moisture
activity
mobility
nutrition
friction/shear
179
mobility
if they CAN move
180
activity
if they ARE moving
181
stage 1 pressure injuries
intact skin with nonblanchable redness
182
stage 2 pressure injuries
partial thickness, loss of dermis, presents as abrasion or blister
183
stage 3 pressure injuries
full thickness, subq tissue may be visible, presents as deep craters
184
stage 4 pressure injuries
full thickness skin loss, tissue necrosis or damage to muscle or bone or surrounding structures
185
most of the time stage 4 require
skin grafting
186
measure depth of injury with
q tip
187
wound and skin lesion documentation
color
characteristics of edges and wound bed
size and shape
depth/tunnels/raised
odor
clock method
drainage characteristics
treatment method, patient tolerance, date, time, signature
188
subjective data of skin
pervious history of skin disease
change in mole
change in pigmentation
excessive dryness or moisture
pruritus (itching)
excessive brusing
189
objective data of skin
color
elevation
pattern or shape
size
location and distribution on body
exudate
190
brisk capillary refill
1-2 sec
191
sluggish capillary refill
over 3 second
192
ABCDE skin mole
asymmetry
border
color
diameter
elevation
193
annular/circular
circles
194
grouped
small groupings
(tryphobia)
195
gyrate
Squiggles
196
linear
in a line
197
a patient who is admitted for liver failure would be likely to show which of the following skin changes
A. Cyanosis
B. Flushing
C. Rubor
D. Jaundice
D
198
when assessing inflammation in a dark skinned person, the nurse may need to
A. assess the skin for cyanosis and swelling
B. assess the oral mucosa for generalized erythema
C. Palpate the skin for edema and increased warmth
D. palpate the skin for tenderness and local areas of ecchymosis
C
