Exam 2✅ Flashcards
Infusion pump
Device that delivers a controlled amount of fluids, liquid nutrients or liquid edications into a client’s body.
Phlebitis
Is characterize by pain, increased skin temperature, and redness along the vein. It is commonly treated by discontinuing the IV line and applying a moist, warm compress over the area.
Infiltration
Is leakage of intravenous solutionsor medication into extravascular tissue. It occurs when the IV catheter is dislodged and fluid infuses into the tissue. It is characterized by edma, pallor, decreased skin temp. Around the site and pain. discontinue IV line and elevate the extremity.
Circulatory overload
Is a systemic complication of IV therapy that causes excess fluid in the circulatory sytem. The characteristics of circulatory overload include dyspnea, elevated blood pressure, edema, moist breath sounds when ausculating the lungs.
Delusions
Beliefs that are not based in reality and that reflects an unconscious need or fear.
Hallucinations
False sensory perceptions: seeing, hearing, smelling, feeling, or tasting objects that are not there.
Perception
Views of oneself and the world, influenced by culture, religion, family, experiences, expectations, and knowledge.
Reticular activating system
Part of the brain respnsible for bringing togethers information from the cerebellum and other parts as well as from the sense organs.
Sensation (sensory) information
Telling a patient what he or she will see, hear, smell, taste, or feel in a particular situation
Sensoristatsis
State of optimal sensory input, which differs for eac perso.
Sensory deprivation
Lack of meaningful sensory stimuli; monotonous input or interference with the processing of information; leads to behavioral changes ranging from boredom to psychosis
Sensory overload
State of arousal in which a person cannot manage the intensity or quantity of incoming sensory stimuli
Sensory perception
The ability to receive sensory input and transform the inputs through various physiologic processes into meaningful information
Accommodation
Test that engages a patient to look at a close object and then look at a distant object to see wheher patient’s pupils constrict to focus on the close object and dialte to see the distant object.
Circulation, motion, sensation (CMS)
A federal organization that pays for healthcare for low-income and elderly people and tracks healthcare outcome.
Expressive aphasia
Communication disorder in which the patient understands and follows directions but cannot verbally aand effectively communicate with the nurse.
Glasgow Coma Scale
Standardized assesment tool used when serial assesments are done for high-risk patients (e.g.; brain tumor, after brain surgery, after a cerebral vascular accident)
Nystagmus
Involuntary, rhythmic oscillations of the eyes
Receptive aphasia
Disorder in which patients cannot understand simple directions
Deliusions
Beliefs that are not based in reality and that refelcts an unconscious need or fear
Hallucinations
False sensory perceptions: seeing, hearing, smelling, feeling or tatsting objects that arae not there.
Perception
Views of onesself and the world, influenced by culture, religion, family, experiences, expectations, and knowledge.
Sensation (sensory) information
Telling a patient what he or she will see, hear, smell, taste, or feel in a particular situation.
Sensory deprivation
Lack of meaningful sensory stimuli; monotonous input or interference with the processing of information; leads to behavioral changes ranging from boredom to psychosis
Sensory overload
State of arousal in which a person cannot manage the intensity or quantity of incoming sensory stimuli
Sensory perception
The ability to receive sensory input and transform the inputs through various physiologic processes into meaningful information
Aphasia
Communication disrder that may affect speech, reading, and writing
Articulation
Enunciation (pronounce clearly) of words and sentences
Attention
Ability to concentrate on and take in specific sensory stimuli.
Cognition
Thinking and awareness; system by which sensory input, past experiences, and emotions are integrated and made meaningful.
Coma
Abnormally deep stupor occurring in illness or as a result of injury; external stimuli fail to arouse the patient
Communication
Interchange of information
Consciousness
State of awareness and full responsiveness to stimuli
Delirium
Reversible disorder of cognition; confusion
Dementia
Cognitive impairment as the result of irreversible organic changes in brain cell function
Comprehension
Capacity for understanding and resoning
Dysarthria
Disorders affecting either single or combined motor control of the muscle speech.
Judgement
Process of reasoning; ability to process incoming stimuli and to determine meanings that encompass many aspects of a situation
Learning
Multidimensional process of acquiring knowledge that depends on symbols, language, classifications, concepts, and other concrete operations along with abstract functions
Memory
Ability to recall a thought atleast once and usually again
Orientation
The basic process by which people know their location in the dimensions of time and place
Perceiving
Process of receiving and interpreting sensory stimuli that function as a basis for understanding, knowing, or learning
reality orientation
Nursing technique to help restore the patient’s awareness of reality
Cranial nerve I
Olfactory; sense of smell
Ask patient to identify mild aromas (ex: vanilla, coffee, chocolate, and cloves)
Cranial nerve II
Optic; vision; ask patient to read Snellen Chart
Cranial nerve III
Oculomotor; pupillary reflex; extraocular eye movement. Assess pupil reaction to penlight. Assess directions of gaze by holding your finger 18inchs from patient’s face. Ask the patient to follow your finger up and down and side to side.
Cranial nerve IV
Lateral and downward movement of eyeball asses directions of gaze. Test with cranial III nerve
Cranial nerve V
TRIgeminal; all three; sensation to corenea, skin of face, nasal (cheek, eyebrows, chin…)
Lightly touch cotton swab to the lateral sclera of the eye to elicit blink (or just ask them to blink). Measure senstaion of touch and pain on the face using cotton wissp
Cranial nerve VI
Abducens lateral movement of eyeall; asses directions of gaze. Test with cranial nerve III
Cranial nerve VII
Facial; facial expression; taste (anterior two thirds of tongue); ask patient to smile, forwn adn raise eyebrows. Ask patient to identify different tatsed on tip and sides of tongue. (Sweet, salt, sour)
Cranial nerve VIII
Auditory; hearing. Assess ability to hear spoken word.
Cranial nerve IX
Glossopharyngeal; taste (posterior tongue), swallowing, movement of tongue. Ask patient to identify tastes on the back of the tongue (salt, sweet, sour). Place tongue blade on posterior tongue while patient says “ah” elicit a gag respnse. Ask patient to move tongue up and down and side to side.
Cranial nerve X
Vagus; swallowing, movement of vocalcords, sensation of pharynx. Assess with cranial nerve IX by observing palate and pharynx move as a patient says “ah”
Cranial nerve XI
Spinal accessory; head and shoulder movement; sk patient to turn head side to side and shrug shoulders against resitance from examiner’s hands.
Cranial nerve XII
Hypoglosssal; tongue position; ask patient to stick out tongue to midline, then move it side to side.
Air embolism
Air bubble in the vascular spacce that may obstruct circulation.
Central venous catheters
A central venous catheter is a thin, flexible tube that is inserted into a vein, usually below the right collarbone, and guided (threaded) into a large vein above the right side of the heart called the superior vena cava. It is used to give intravenous fluids, blood transfusions, chemotherapy, and other drugs.
Colloid
Fluids that contain proteins or starch moldecules