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Nursing > Exam 1 Part 1 > Flashcards

Exam 1 Part 1 Flashcards

1
Q

When do you check vital signs?

A

On admission
Change in client’s condition
Change in LOC
Before and after any invasive procedure
Before and after activities that may cause a change
Before administering medications
Per facility policy

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2
Q

what is a temperature range for a healthy adult?

A

96.4 — 99.5

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3
Q

what is a temparture range for a older adult?

A

96.4—98.3

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4
Q

what is hyperthermia?

A

A temperature above the patients normal body temperature

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5
Q

what are the causes of hyperthermia?

A

cancer
illness
trauma
surgery

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6
Q

what are the benefits of hyperthermia?

A

start of the immune system
initial sign that something is wrong

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7
Q

what are the signs and symptoms of hyperthermia?

A

loss of appetite
shivering
hot dry skin
flushed face
thirst
muscle aches
fatigue
confusion
increased pulse and respirations

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8
Q

what pharmacalogical interventions do we have for hyperthermia?

A

antipyretics
NSAIDS
Acetametaphin

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9
Q

what non pharmacological interventions do we have for hyperthermia?

A

Cool sponge bath

Increased fluid intake

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10
Q

what is hypothermia?

A

a decrease in temp below the patients normal temperature

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11
Q

What are the causes of hypothermia?

A

exposure to the cold
chronic conditions
perioperative clients/ post op
Newborns

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12
Q

What are the signs and symptoms of hypothermia?

A

Poor Coordination
Slurred Speech
Poor judgement
Amnesia
Hallucinations
Vital Signs decrease

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13
Q

what treatments do we have for hypothermia?

A

warming blankets
warm fluids
additional clothing

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14
Q

what are the routes for taking temp?

A

Sublingual…Oral
Tympanic…ear
Temporal…forehead
Rectal
Axillary…armpit

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15
Q

what are the advantages for taking an oral temp?

A

most common

easily accesible

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16
Q

what are the contraindications for a oral temperature

A

intake of cold or hot food
smoking
chewing gum

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17
Q

what are the advantages of a tmypanic temperature?

A

easily accesible

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18
Q

what are contraindications for a tympanic temP?

A

drainage from ear
ear pain
ear infection
scars on the tympanic membrane

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19
Q

what are the advantages of a temporal temp

A

more accurate than axiallary

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20
Q

what are contraindications of a temporal temp?

A

forehead covering

affected by external temparatures

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21
Q

what are the advantages of a rectal temp

A

most accurate

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22
Q

what are contraindications for a rectal temp?

A

special thermometer
heart disease or surgery
low platelet count
neutropenic precautions
spinal cord injuries…due to vagus nerve stimulation

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23
Q

When would you use axillary temp

A

use when sublingual/oral or rectal sites are contraindicated

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24
Q

what are the contraindications for axillary temp?

A

least accurate of them all
unable to keep arm down until reading is complete

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25
Q

what is the normal adult range for pulse?

A

60-100

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26
Q

what are the characteristics of a pulse?

A

rate…rhythm…amplitude

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27
Q

what factors affect pulse?

A

age…..biological sex…physical activity…fever…stress…meds…presence of a disease

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28
Q

what is tachcardia?

A

when the pulse is between 101-180

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29
Q

what is bradycardia?

A

when the pulse is below 60

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30
Q

what is amplitude?

A

described the quality or fullness of the sound

0…absent
+1…diminished/weaker
+2…brisk/normal
+3…bounding

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31
Q

what is a normal range of respirations?

A

12-20

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32
Q

what are the characteristics of respirations?

A

rhythm and depth?

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33
Q

what factors affect respiratory rate?

A

age, exercise, acid base balance, brain lesions, meds, increased altitude, resp disease, anemia, anxiety, pain

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34
Q

what is acidosis and what does it do to your breathing?

A

it is when your blood becomes too acidic….this increases respirations

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35
Q

what is apnea?

A

temporary stop in respirations

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36
Q

what is tachypnea?

A

rate greater than 24

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37
Q

what is bradypnea?

A

respirations less than 10

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38
Q

what are the three kinds of respiration rhythms?

A

apnea, tachypnea, bradypnea

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39
Q

what are the two kinds of respiration depths?

A

hyperventilation and hypoventilation

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40
Q

what is hyperventilation?

A

increased rate and depth

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41
Q

what is hypoventilation?

A

decreased rate and depth

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42
Q

what does a pulse ox measure?

A

the percentage of oxygen in the blood

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43
Q

what is the normal range for oxygen in the blood?

A

95 to 100

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44
Q

what factors can affect pulse ox reading?

A

Cold hands
wrong location
fingernail polish
equipment malfunctin

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45
Q

what does anemia do to your rate and depth of respirations?

A

increased rate and decreased depth

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46
Q

what does anxiety do to your rate and depth of respirations?

A

increased rate and increased depth

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47
Q

what does narcotics do to your rate and depth of respirations?

A

decreased rate and depth

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48
Q

what does cocaine do to your rate and depth of respirations?

A

increased rate and increased depth

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49
Q

what does acute pain do to your rate and depth of respirations?

A

increased rate and decreased depth

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50
Q

what is a normal range for blood pressure

A

Systolic 90 - 120
Dystolic 60 - 80

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51
Q

what is considered hypertension?

A

Anything over 130 / 80

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52
Q

what is considered hypotension?

A

anything under 90 / 60

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53
Q

what factors affect blood pressue?

A

age, cardiac rhythm, bio sex, food intake, exercise, weight, emotional state, body position, race, meds

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54
Q

what factors can give a false low BP

A

hearing deficit
noise around you
applying too wide of a cuff
inserting stethoscope incorrectly
releasing valve too rapidly

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55
Q

what factors can give a false high BP

A

incorrect calibration
applying a cuff that is too narrow
releasing valve too slow
reinflating bladder during descent

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56
Q

who is at risk for hypertension?

A

family history, race, sleep apena

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57
Q

what is orthostatic hypotension?

A

when your blood pressure drops when suddenly getting up

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58
Q

what are nonpharmacological interventions for hypotension?xxxxxx

A

increased water intake,

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59
Q

what is transient bacteria?

A

bacteria that move from surface to surface and dont live on a specific location

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60
Q

what is resident bacteria?

A

bacteria that live on a surface

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61
Q

what is the infection cycle?

A

1) infection agent
2) the reservoir..or the person holding the sickness
3) portal of exit..the place it comes out of
4) mode of transmission…how it spreads
5)portal of entry…how the person get the disease
6)susceptible host…someone that has a compromised immune

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62
Q

what are standard precations?

A

precautions that all staff take when dealing with pateints

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63
Q

what is included in standard precautions?

A

gown, mask, gloves when coming into contact with bodily fluids

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64
Q

what are the three transmission based precautions?

A

contact, droplet, airborne

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65
Q

what is included in contact precations?

A

gound and gloves

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66
Q

what is included in droplet preacautions?

A

mask, eye protection, gound, gloves

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67
Q

what is included in airborne preacautions?

A

N95, gound, eye protection, gloves

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68
Q

what are the steps for donning PPE?

A

Gown
Mask
Goggles
Gloves

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69
Q

what are the steps of doffing PPE

A

Gloves
Goggles
Gown
Mask

Gown/Gloves
Goggles
Mask

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70
Q

what is the nurses role in preventing skin integrity issues?

A

Keeping the skin clean

Doing assessments

Turning as needed

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71
Q

what factors influence person hygiene?

A

Culture
socioecomic status
religion
developmental stage
state of health
personal preferences

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72
Q

what safety ideas should you keep in mind during bed making?

A

the rails being up or down
have the bed up when making
have the bed down when finished

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73
Q

why are bariatric patients at risk for skin infection?

A

moisture in their folds

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74
Q

what is a immaltant?

A

a mousturizer that you use after bathing

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75
Q

in healthy patients do you need to check peri area every day?

A

You dont have to check everyday unless they mention something is wrong….check every other day

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76
Q

what area of the body is susceptible to bacteria growth?

A

peri area

77
Q

what are ADLs

A

avtivites of daily living…bathing dressing, continence, feeding,

78
Q

what is the Katz

A

this is an assessment tool to determine indepence of a patient

79
Q

what is fowlers position?

A

between 30 and 90

80
Q

what is supine?

A

on your back

81
Q

what is sims?

A

laying on side

82
Q

what is prone?

A

laying on stomach

83
Q

what is sleep?

A

state of altered consciousness throughout which varying degrees of stimuli preclude wakefulness

84
Q

afebrile

A

condition in which the body temperature is not elevated

85
Q

apnea

A

abscence of breathing

86
Q

auscultatory gap

A

period of diminished or absent Korotkoff sounds; it occurs during the manual measurement of blood pressure in the latter part of phase I and during phase II

87
Q

blood pressure

A

force of blood against artery walls

88
Q

what is the diastolic pressue?

A

least amout of pressure exerted on the artery walls whne the heart is at rest

89
Q

what is dyspnea?

A

difficult or labored breathing

90
Q

what is dysrhythmia?

A

irregular heart beat

91
Q

what is eupnea?

A

Normal breathing

92
Q

what is fibrle?

A

when body temp is elevated

93
Q

what is pyrexia

A

fever of the body

94
Q

what are kortokoff sounds?

A

series of sounds that correspond to changes in blood flow when pressure is released

95
Q

what is orthopnea?

A

type of dyspnea which breathing is easier when patients sits or stands

96
Q

what is orthostatic hypotension?

A

drop in BP when standing

97
Q

what is pulse deficit?

A

difference between apical and radial pulses

98
Q

what is pyrexia?

A

raised body temp

99
Q

what systolic pressure?

A

highest point of pressure on arterial walls when heart contracts

100
Q

what is aerobic bacteria?

A

bacteria that require oxygen to live and grow

101
Q

what is airborne transmission

A

disease that is spread through the air less than 5mcm

102
Q

what is anearobic bacteria?

A

bacteria that can live without oxygen

103
Q

what is antibody?

A

produced by the body to fight off specific antigen

104
Q

what is antimicrobials

A

antibacterial agent

105
Q

what is asepsis?

A

abscence of disease

106
Q

what is bundles?

A

things that should be done to reduce infection

107
Q

direct contact

A

way for organisms to enter the body that involves proximity between the susceptible host and an infected person or a carrier, such as through touching, kissing, or sexual intercourse

108
Q

what is droplet transmission?

A

transmission of particles greater than 5mccm

109
Q

what is endemic?

A

something that occurs in a region that can be predicted

110
Q

what is an endogenous infection?

A

an infection that stated within the body

111
Q

what is an exogenous infection?

A

an infection that was aquired from outside

112
Q

what is a bacteria?

A

the most common cause of infection

113
Q

what are some examples of bacterial infection?

A

E coli, MRSA, Staph, Meningitis

114
Q

what is a fungi?

A

plant like organisms that cause infection

115
Q

what are some fungi infections?

A

athletes foot, jock itch, yeast infection

116
Q

what is iatrogenic?

A

infection that occurs because of a treament

117
Q

what is an infection?

A

disease that results in pathogens in the body

118
Q

what is a pathogen?

A

disease producing micoorganism

119
Q

what is a resevoir?

A

habitat for organisms to grow

120
Q

what is sterilization?

A

the process by which all microorganisms, including spores, are destroyed; (2) surgical procedure performed to render a person infertile

121
Q

What is a vector?

A

non human carriers of disease that can spread to us

122
Q

what are some examples of vectors?

A

mosquitoes, ticks, like

123
Q

what is virulence?

A

ability to produce disease

124
Q

what is a virus?

A

the smallest of all microogranisms..non living

125
Q

what are examples of a virus?

A

Flu, covid, HIV

126
Q

what is alopecia?

A

loss of hair or baldness

127
Q

what are caries?

A

cavaties of the teeth

128
Q

what is cerumen?

A

ear wax

129
Q

what is cheilosis?

A

chapped lips

130
Q

what is gingivitis?

A

inflimmation of gums

131
Q

what is glossitis?

A

inflimmation of the toungue

132
Q

what is halitosis?

A

bad breath

133
Q

what is pediculosis?

A

lice

134
Q

what is peridontitis?

A

bad inflimmation of the gums

135
Q

what is plaque?

A

visible bacterial film on teeth

136
Q

what is stomatitis?

A

inflammation of oral mucus

137
Q

what is tartar?

A

hard deposit on teeth from plaque

138
Q

what is adventitious breath sounds?

A

abnormal breath sound heard over lungs

139
Q

what is auscultation?

A

listening for sounds within the body

140
Q

what is a comprehensive health assessment?

A

complete health history and physical assessment

141
Q

what is cyanosis?

A

bluish coloring of the skin

142
Q

what is diaphoresis?

A

excessive amount of sweating

143
Q

what is eccymosis?

A

collection of blood under the skin….bruise

144
Q

what is edema?

A

accumulation of fluid in extracellular space

145
Q

what is erythema?

A

redness of skin

146
Q

what is pallor?

A

paleness of skin

147
Q

what is palpation?

A

method of felling a body part with fingers or hands

148
Q

what is active exercise?

A

joint movement by someone else

149
Q

what is atrophy?

A

the decrease in size of the body

150
Q

what is contractures?

A

permanent contracted muscles

151
Q

what is flaccidity?

A

decrease muscle tone

152
Q

what is paralysis?

A

absence of strength due to nervous sysyem impairment

153
Q

what is circadian rhythms?

A

rhythm that completes a full cycle every 24 hours;

154
Q

enuresis

A

involuntary urination; most often used to refer to a child who involuntarily urinates during the night

155
Q

what is hypersomnia?

A

excessive sleeping especially during the day time

156
Q

what is insomnia?

A

difficulty falling asleep

157
Q

what is melatonin?

A

a chemical produced by the body to decrease wakefullness

158
Q

what is narcolepsy?

A

uncontrolled falling asleep

159
Q

what is NREM

A

non rapid eye movement…found in four stages of the sleep cycle

160
Q

what is sleep apnea?

A

temporary stopping of breathing due to airway closing

161
Q

what is parasomnias?

A

patterns of waking behavior that occur during sleep

162
Q

what are some examples of parasomnias?

A

sleep walking, sleep talking, erections

163
Q

what is REM

A

rapid eye movement

164
Q

is it easy or hard to wake someone in rem sleep?

A

hard

165
Q

what percentage of sleep is in REM?

A

20-25

166
Q

what is rest?

A

decreased state of activity

167
Q

what is RLS?

A

restless leg syndrome…causing tingling

168
Q

what is the sleep cycle stages?

A

xxxxq

169
Q

what is sleep deprivation?

A

a decrease in the amount, consistency, and quality of sleep from decreased REM or NREM sleep

170
Q

what is somnambulism?

A

sleep walking

171
Q

what is involved in sleep health?

A

duration, continuity, time it takes to sleep, and how you feel

172
Q

what are the stages of sleep?

A

Wake….NREM 1….NREM 2…NREM 3….NREM 4…NREM 3…NREM 2…REM…NREM 2

173
Q

what is stage 1 NREM

A

Initial falling asleep

Light sleep/jerking body

Only lasts minutes

5% of sleep

174
Q

what is stage NREM stage 2

A

Sleep begins

Light Sleep

50-55% of sleep

175
Q

NREM stage 3

A

Depth of sleep increases

10% of sleep

176
Q

NREM stage 4

A

Greatest depth of sleep

waking from sleep is difficult

Vitals decrease

10%

177
Q

REM sleep

A

Eyes darting, small muscles twitches, irregular respiarations/pulse/bp

Metabolism increases

20-25% of sleep

178
Q

what is acute pain?

A

episode of pain lasting from seconds to 6 months

179
Q

what is addiction?

A

pattern of compulsive use of substances

180
Q

what is analgesic?

A

agent used to relieve pain

181
Q

what is breakthrough pain?

A

temporary flare up of moderate to severe pain when taking around the clock pain med

182
Q

what is chronic pain?

A

pain that lasts for 6 months or longer

183
Q

what is cutaneous pain?

A

superficial pain usually involving the skin

184
Q

what are endorphins?

A

morphine like substances released by the body to alter perception of pain

185
Q

what is exacerbation?

A

period in chronic illness when symptoms reappear

186
Q

what is gate control theory

A

explains that excitatroy pain stimuli can be blocked`

187
Q

what is intractable?

A

severe pain that is resistant to pain relief measures

188
Q

what is modulation?

A

process by which pain is inhibited or modified….by anestheics or analgesics

Nursing (18 decks)

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