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► Nursing Notes > Exam 1: NR 414 > Flashcards

Exam 1: NR 414 Flashcards

(85 cards)

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1
Q

What are the 4 components of Diagnostics

A
  1. cues,
  2. info,
  3. signs,
  4. symptoms,
  5. lab data
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2
Q

Diagnosis

A

Valid influences, compare “clusters”, identify related factors

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3
Q

What are some components of Critical Thinking

A

identify assumptions, validate, normal/abnormal, relevance, inconsistencies, patterns, missing info, actual & potential risk, setting priorities, patient centered, evaluate

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4
Q

4 Types of Data

A
  1. Complete Health Data
  2. Episodic/Problem Centered/Focus data
  3. Follow-up data
  4. Emergency data base (ABCs)
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5
Q

3 Phases of Interview

A

1) Process of Communication 2) Internal 3) External Factors

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6
Q

Process of Communication means.

A

sending/receiving internal/external facotrs

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7
Q

Techniques of Communication x6

A
  1. open vs closed ended questions
  2. nonverbal skills,
  3. eye contact,
  4. voice,
  5. touch,
  6. dress
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8
Q

What are ways we overcome communication barriers

A

interpreters, vocal cues, action cues, object cues, space/touch

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9
Q

What are 2 types of measuring mental disorders

A

organic & psychiatric

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10
Q

Alert & Oriented x 4 (behavior orientation)

A

1) person 2) place 3) time 4)situation (what brought you here)

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11
Q

What are 4 components of mental health assessment

A

1) appearance 2) behavior 3) cognition 4) thought processes

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12
Q

QPR stands for

A

question, persuade, refer

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13
Q

Broca refers to

A

physical incapability to speak

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14
Q

Wernicke

A

not being able to speak correctly

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15
Q

What is ethnicity

A

a group having similar traits: common language, common heritage and cultural similarities

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16
Q

Race

A

relates more towards the appearance of a person. Biologically with inherited genetic traits.

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17
Q

Heritage

A

ancestors of a person

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18
Q

What is a database?

A

Sub & Objective data gathered from a patient plus the results of any diagnostic studies completed

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19
Q

What does PQRSTU Stand for

A

1) Provocative 2)Quality/Quantity 3)Region/Radiation 4) Severity 5) Timing 6)Understanding

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20
Q

How would you describe the pitch of a sound wave obtained by a percussion

A

number of vibrations per second

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21
Q

Which aperture is used for a patient with undilated pupils

A

small

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22
Q

During gen survey what are the 4 areas of interest

A

1)Appearance 2)Body structure 3)Mobility 4)Behavior

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23
Q

A normal pulse for a patient is..

A

2+

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24
Q

What is pulse pressure

A

the difference between systolic and diastolic pressure

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25
What is the mean arterial pressure
diastolic pressure plus one third pulse pressure
26
what is nociception
pain receptors
27
neuropathic pain
burning painful sensation that moves around toes and bottoms of feet.
28
Complex Regional Pain I
chronic pain that usually affects an arm or a leg.
29
P-OLDCARTS
previous hx, onset, location, duration, character, aggravating, radiation, timing, severity
30
What are the 4 steps in a regular physical exam
1) inspection 2)Palpation 3)Percussion 4)Auscultation
31
What is normal temp in axillary
97.6F or 38.4C
32
What is normal temp in tympanic membrane?
98.6F
33
What is the conversion Celsius to Fahrenheit
C= 5/9 (f-32)
34
What is the conversion for Fahrenheit to Celsius
(9/5 x C) +32
35
What does a doppler do?
picks up changes in sound frequency as blood flows
36
When is mobility decreased
with edema
37
What does sterile mean?
* no life * using special gases * high heat
38
When is surgical apses necessary?
* intentional perforation of the skin * body cavity, not exposed to outside
39
What are the golden rules of surgical apses
* an object below the waist is contaminated, because it is out of range of vision * never turn your back on a sterile field * keep trashcan close by, or drop on ground * Both patient and provider wear mask * If you break sterile technique- START OVER * 1" border
40
Name 5 types where patient needs surgical asepsis technique
1. Open Body Cavity 2. Catheter 3. Burns 4. Central Line
41
What are 6 maor things you want to palpate for in skin hair nails
1. Temperature 2. texture- use finger tips 3. moisture 4. diaphoresis (sweating) 5. thickness 6. Edema
42
How is edema measured?
* 4 point scale * 1+ = 2mm * 2+ = 4mm......
43
3 Common types of birthmarks
1. freckles 2. junctional nevus 3. compound nevus
44
junctional nevus
45
Compound Nevus
46
What are the abnormal signs for pigmented lesions
ABCDE
47
ABCDE stands for
* **A**symmetry * **B**order * **C**olor variation * **D**iameter grater than 6mm * **E**levation or Enlargement
48
* Confluent Lesion * ex hives//uriticaria
49
* Discrete lesion * Skin tags//acne
50
Gyrate Lesion
51
* zosteriform * linear around unilateral nerve * ex: herpes
52
* Polycyclic * i.e. psoriasis * anular lesions grow together
53
What are primary skin lesions x6
* Macular/Patch * Papule/Plaque * Nodule/Tumor * Vesicle/bulla * Cyst * Postule
54
* Macule * Patch larger than 1 cm * flat not raised
55
* **Papule** * Plaque larger than 1 cm * can feel, slightly elevated * mole wart
56
* Nodule * tumor larger than 3 cm
57
* **Wheal** * Urticaria-hives * raised irregular shape due to edema * mosquito bites, allergies
58
* **Vesicle** * Bulla- larger than 1cm * a blister, herpes chicken pox, shingles
59
What are some secondary Skin lesions?
* Crust * Scale * fissure * erosion * ulcer * Excoriation * scar * atrophic scar * lichenfication * Keloid
60
* **Scale** * compact flakes of skin
61
* Keloid * hypertrophic scar * elevetated skin by excess scar tisue
62
* **Pressure Ulcer Stage I** * red but ubroken * will not blanch
63
* Stage 3 ulcer * extending into subcutaneous tissue * resembling a crater
64
* Stage IV Ulcer * breaks through all skin layers * visible bone or tendons
65
What are some vascular lesions
* petechiae * purpura * hematoma * contusion
66
Epidermis layer
* basal layer, * thin, * stratum corneum
67
Dermis Layer
* collagen * elastic tissue
68
Subcutaneous layer
* adipose tissue
69
When irrigating a wound, how would the nurse know the right amount of pressure to apply?
between 5 and 15psi
70
Which device is used for wound irrigation?
19 gauge needle attached to 35 mL syringe
71
Elsevier: What is the nursing action to set up suction for a hemovac drainage system?
the nurse should compress it firmly and replace the plug.
72
Elsevier: Which imaging study or diagnostic test would the nurse review to determine if the pressure ulcer on a patient’s left heel is infected?
Culture & sensitivity
73
Elsevier: What is the proper method for cleansing the evacuation port of a wound drainage system?
Wipe it with an alcohol sponge.
74
Braden Scale
Risk for skin breakdown/Pressure ulcer
75
What is the *primary intention* for wound healing?
* tissue surfaces have been approximated * low tissue loss * remove dressings after drainage
76
What is *secondary intention* for wound healing?
* considerable tissue loss * edges cannot be drawn together * longer to heal * scarring is greater * infection risk * Pressure ulcers * continue dressings for moisture * assist debridement
77
What are the phases for a full thickness wound repair?
1. Hemostasis (fibrin) 2. Inflammatory phase 3. Proliferative phase- *epithelial* 4. Remodeling- can take years
78
What is required in the delivery of culturally congruent care?
* knowledge * skills * attitudes
79
What is an example of a nurse stereotyping a patient?
do you bathe and use deodorant more than one time a week?
80
What are appropriate questions to ask a native american?
1. do you use folk remedies 2. do you have a family physician 3. do you use a shaman
81
What is an example of data validation
* comparing values with previous values * report to charge nurse
82
What are the steps for a nursing diagnosis?
1. review assessment data 2. cluster 3. diagnostic label 4. contet of pt's health probl and select related factor
83
What could be indicated when a reddened area blances on fingertip touch?
blanching hyperemia. Body overcoming ischemic episode
84
To determine wound infection, where should the specimen be taken?
wound, after it has been cleaned with normal saline
85
After surgery a patient coughs and opens up a wound. What is the nurse's first intervention?
cover with saline-soaked towels and notify surgical team. ## Footnote **Evisceration**

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