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
2
Q
what is a temperature range for a healthy adult?
A
96.4 — 99.5
3
Q
what is a temparture range for a older adult?
A
96.4—98.3
4
Q
what is hyperthermia?
A
A temperature above the patients normal body temperature
5
Q
what are the causes of hyperthermia?
A
cancer
illness
trauma
surgery
6
Q
what are the benefits of hyperthermia?
A
start of the immune system
initial sign that something is wrong
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
8
Q
what pharmacalogical interventions do we have for hyperthermia?
A
antipyretics
NSAIDS
Acetametaphin
9
Q
what non pharmacological interventions do we have for hyperthermia?
A
Cool sponge bath
Increased fluid intake
10
Q
what is hypothermia?
A
a decrease in temp below the patients normal temperature
11
Q
What are the causes of hypothermia?
A
exposure to the cold
chronic conditions
perioperative clients/ post op
Newborns
12
Q
What are the signs and symptoms of hypothermia?
A
Poor Coordination
Slurred Speech
Poor judgement
Amnesia
Hallucinations
Vital Signs decrease
13
Q
what treatments do we have for hypothermia?
A
warming blankets
warm fluids
additional clothing
14
Q
what are the routes for taking temp?
A
Sublingual…Oral
Tympanic…ear
Temporal…forehead
Rectal
Axillary…armpit
15
Q
what are the advantages for taking an oral temp?
A
most common
easily accesible
16
Q
what are the contraindications for a oral temperature
A
intake of cold or hot food
smoking
chewing gum
17
Q
what are the advantages of a tmypanic temperature?
A
easily accesible
18
Q
what are contraindications for a tympanic temP?
A
drainage from ear
ear pain
ear infection
scars on the tympanic membrane
19
Q
what are the advantages of a temporal temp
A
more accurate than axiallary
20
Q
what are contraindications of a temporal temp?
A
forehead covering
affected by external temparatures
21
Q
what are the advantages of a rectal temp
A
most accurate
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
23
Q
When would you use axillary temp
A
use when sublingual/oral or rectal sites are contraindicated
24
Q
what are the contraindications for axillary temp?
A
least accurate of them all
unable to keep arm down until reading is complete
25
what is the normal adult range for pulse?
60-100
26
what are the characteristics of a pulse?
rate...rhythm...amplitude
27
what factors affect pulse?
age.....biological sex...physical activity...fever...stress...meds...presence of a disease
28
what is tachcardia?
when the pulse is between 101-180
29
what is bradycardia?
when the pulse is below 60
30
what is amplitude?
described the quality or fullness of the sound
0...absent
+1...diminished/weaker
+2...brisk/normal
+3...bounding
31
what is a normal range of respirations?
12-20
32
what are the characteristics of respirations?
rhythm and depth?
33
what factors affect respiratory rate?
age, exercise, acid base balance, brain lesions, meds, increased altitude, resp disease, anemia, anxiety, pain
34
what is acidosis and what does it do to your breathing?
it is when your blood becomes too acidic....this increases respirations
35
what is apnea?
temporary stop in respirations
36
what is tachypnea?
rate greater than 24
37
what is bradypnea?
respirations less than 10
38
what are the three kinds of respiration rhythms?
apnea, tachypnea, bradypnea
39
what are the two kinds of respiration depths?
hyperventilation and hypoventilation
40
what is hyperventilation?
increased rate and depth
41
what is hypoventilation?
decreased rate and depth
42
what does a pulse ox measure?
the percentage of oxygen in the blood
43
what is the normal range for oxygen in the blood?
95 to 100
44
what factors can affect pulse ox reading?
Cold hands
wrong location
fingernail polish
equipment malfunctin
45
what does anemia do to your rate and depth of respirations?
increased rate and decreased depth
46
what does anxiety do to your rate and depth of respirations?
increased rate and increased depth
47
what does narcotics do to your rate and depth of respirations?
decreased rate and depth
48
what does cocaine do to your rate and depth of respirations?
increased rate and increased depth
49
what does acute pain do to your rate and depth of respirations?
increased rate and decreased depth
50
what is a normal range for blood pressure
Systolic 90 - 120
Dystolic 60 - 80
51
what is considered hypertension?
Anything over 130 / 80
52
what is considered hypotension?
anything under 90 / 60
53
what factors affect blood pressue?
age, cardiac rhythm, bio sex, food intake, exercise, weight, emotional state, body position, race, meds
54
what factors can give a false low BP
hearing deficit
noise around you
applying too wide of a cuff
inserting stethoscope incorrectly
releasing valve too rapidly
55
what factors can give a false high BP
incorrect calibration
applying a cuff that is too narrow
releasing valve too slow
reinflating bladder during descent
56
who is at risk for hypertension?
family history, race, sleep apena
57
what is orthostatic hypotension?
when your blood pressure drops when suddenly getting up
58
what are nonpharmacological interventions for hypotension?xxxxxx
increased water intake,
59
what is transient bacteria?
bacteria that move from surface to surface and dont live on a specific location
60
what is resident bacteria?
bacteria that live on a surface
61
what is the infection cycle?
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
62
what are standard precations?
precautions that all staff take when dealing with pateints
63
what is included in standard precautions?
gown, mask, gloves when coming into contact with bodily fluids
64
what are the three transmission based precautions?
contact, droplet, airborne
65
what is included in contact precations?
gound and gloves
66
what is included in droplet preacautions?
mask, eye protection, gound, gloves
67
what is included in airborne preacautions?
N95, gound, eye protection, gloves
68
what are the steps for donning PPE?
Gown
Mask
Goggles
Gloves
69
what are the steps of doffing PPE
Gloves
Goggles
Gown
Mask
Gown/Gloves
Goggles
Mask
70
what is the nurses role in preventing skin integrity issues?
Keeping the skin clean
Doing assessments
Turning as needed
71
what factors influence person hygiene?
Culture
socioecomic status
religion
developmental stage
state of health
personal preferences
72
what safety ideas should you keep in mind during bed making?
the rails being up or down
have the bed up when making
have the bed down when finished
73
why are bariatric patients at risk for skin infection?
moisture in their folds
74
what is a immaltant?
a mousturizer that you use after bathing
75
in healthy patients do you need to check peri area every day?
You dont have to check everyday unless they mention something is wrong....check every other day
76
what area of the body is susceptible to bacteria growth?
peri area
77
what are ADLs
avtivites of daily living...bathing dressing, continence, feeding,
78
what is the Katz
this is an assessment tool to determine indepence of a patient
79
what is fowlers position?
between 30 and 90
80
what is supine?
on your back
81
what is sims?
laying on side
82
what is prone?
laying on stomach
83
what is sleep?
state of altered consciousness throughout which varying degrees of stimuli preclude wakefulness
84
afebrile
condition in which the body temperature is not elevated
85
apnea
abscence of breathing
86
auscultatory gap
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
blood pressure
force of blood against artery walls
88
what is the diastolic pressue?
least amout of pressure exerted on the artery walls whne the heart is at rest
89
what is dyspnea?
difficult or labored breathing
90
what is dysrhythmia?
irregular heart beat
91
what is eupnea?
Normal breathing
92
what is fibrle?
when body temp is elevated
93
what is pyrexia
fever of the body
94
what are kortokoff sounds?
series of sounds that correspond to changes in blood flow when pressure is released
95
what is orthopnea?
type of dyspnea which breathing is easier when patients sits or stands
96
what is orthostatic hypotension?
drop in BP when standing
97
what is pulse deficit?
difference between apical and radial pulses
98
what is pyrexia?
raised body temp
99
what systolic pressure?
highest point of pressure on arterial walls when heart contracts
100
what is aerobic bacteria?
bacteria that require oxygen to live and grow
101
what is airborne transmission
disease that is spread through the air less than 5mcm
102
what is anearobic bacteria?
bacteria that can live without oxygen
103
what is antibody?
produced by the body to fight off specific antigen
104
what is antimicrobials
antibacterial agent
105
what is asepsis?
abscence of disease
106
what is bundles?
things that should be done to reduce infection
107
direct contact
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
what is droplet transmission?
transmission of particles greater than 5mccm
109
what is endemic?
something that occurs in a region that can be predicted
110
what is an endogenous infection?
an infection that stated within the body
111
what is an exogenous infection?
an infection that was aquired from outside
112
what is a bacteria?
the most common cause of infection
113
what are some examples of bacterial infection?
E coli, MRSA, Staph, Meningitis
114
what is a fungi?
plant like organisms that cause infection
115
what are some fungi infections?
athletes foot, jock itch, yeast infection
116
what is iatrogenic?
infection that occurs because of a treament
117
what is an infection?
disease that results in pathogens in the body
118
what is a pathogen?
disease producing micoorganism
119
what is a resevoir?
habitat for organisms to grow
120
what is sterilization?
the process by which all microorganisms, including spores, are destroyed; (2) surgical procedure performed to render a person infertile
121
What is a vector?
non human carriers of disease that can spread to us
122
what are some examples of vectors?
mosquitoes, ticks, like
123
what is virulence?
ability to produce disease
124
what is a virus?
the smallest of all microogranisms..non living
125
what are examples of a virus?
Flu, covid, HIV
126
what is alopecia?
loss of hair or baldness
127
what are caries?
cavaties of the teeth
128
what is cerumen?
ear wax
129
what is cheilosis?
chapped lips
130
what is gingivitis?
inflimmation of gums
131
what is glossitis?
inflimmation of the toungue
132
what is halitosis?
bad breath
133
what is pediculosis?
lice
134
what is peridontitis?
bad inflimmation of the gums
135
what is plaque?
visible bacterial film on teeth
136
what is stomatitis?
inflammation of oral mucus
137
what is tartar?
hard deposit on teeth from plaque
138
what is adventitious breath sounds?
abnormal breath sound heard over lungs
139
what is auscultation?
listening for sounds within the body
140
what is a comprehensive health assessment?
complete health history and physical assessment
141
what is cyanosis?
bluish coloring of the skin
142
what is diaphoresis?
excessive amount of sweating
143
what is eccymosis?
collection of blood under the skin....bruise
144
what is edema?
accumulation of fluid in extracellular space
145
what is erythema?
redness of skin
146
what is pallor?
paleness of skin
147
what is palpation?
method of felling a body part with fingers or hands
148
what is active exercise?
joint movement by someone else
149
what is atrophy?
the decrease in size of the body
150
what is contractures?
permanent contracted muscles
151
what is flaccidity?
decrease muscle tone
152
what is paralysis?
absence of strength due to nervous sysyem impairment
153
what is circadian rhythms?
rhythm that completes a full cycle every 24 hours;
154
enuresis
involuntary urination; most often used to refer to a child who involuntarily urinates during the night
155
what is hypersomnia?
excessive sleeping especially during the day time
156
what is insomnia?
difficulty falling asleep
157
what is melatonin?
a chemical produced by the body to decrease wakefullness
158
what is narcolepsy?
uncontrolled falling asleep
159
what is NREM
non rapid eye movement...found in four stages of the sleep cycle
160
what is sleep apnea?
temporary stopping of breathing due to airway closing
161
what is parasomnias?
patterns of waking behavior that occur during sleep
162
what are some examples of parasomnias?
sleep walking, sleep talking, erections
163
what is REM
rapid eye movement
164
is it easy or hard to wake someone in rem sleep?
hard
165
what percentage of sleep is in REM?
20-25
166
what is rest?
decreased state of activity
167
what is RLS?
restless leg syndrome...causing tingling
168
what is the sleep cycle stages?
xxxxq
169
what is sleep deprivation?
a decrease in the amount, consistency, and quality of sleep from decreased REM or NREM sleep
170
what is somnambulism?
sleep walking
171
what is involved in sleep health?
duration, continuity, time it takes to sleep, and how you feel
172
what are the stages of sleep?
Wake....NREM 1....NREM 2...NREM 3....NREM 4...NREM 3...NREM 2...REM...NREM 2
173
what is stage 1 NREM
Initial falling asleep
Light sleep/jerking body
Only lasts minutes
5% of sleep
174
what is stage NREM stage 2
Sleep begins
Light Sleep
50-55% of sleep
175
NREM stage 3
Depth of sleep increases
10% of sleep
176
NREM stage 4
Greatest depth of sleep
waking from sleep is difficult
Vitals decrease
10%
177
REM sleep
Eyes darting, small muscles twitches, irregular respiarations/pulse/bp
Metabolism increases
20-25% of sleep
178
what is acute pain?
episode of pain lasting from seconds to 6 months
179
what is addiction?
pattern of compulsive use of substances
180
what is analgesic?
agent used to relieve pain
181
what is breakthrough pain?
temporary flare up of moderate to severe pain when taking around the clock pain med
182
what is chronic pain?
pain that lasts for 6 months or longer
183
what is cutaneous pain?
superficial pain usually involving the skin
184
what are endorphins?
morphine like substances released by the body to alter perception of pain
185
what is exacerbation?
period in chronic illness when symptoms reappear
186
what is gate control theory
explains that excitatroy pain stimuli can be blocked`
187
what is intractable?
severe pain that is resistant to pain relief measures
188
what is modulation?
process by which pain is inhibited or modified....by anestheics or analgesics
