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Fundamentals- BSN1 > Exam 2 > Flashcards

Exam 2 Flashcards

1
Q

Failure to produce or excrete 50 to 100mL of urine in 24 hours

A

Anuria

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2
Q

Reduced volume: less than 400 mL in 24 hours

A

Oliguria

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3
Q

excessive production and excretion of urine

A

Polyuria

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4
Q

excessive urination at night

A

Nocturia

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5
Q

Painful urination

A

Dysuria

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6
Q

Blood in urine

A

Hematuria

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7
Q

Inability to control urination

A

Urinary incontinence

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8
Q

Inability to empty the bladder fully

A

Urinary Retention

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9
Q

How much urine does an adult pass in one day

A

1-2 quarts (960-1920 ml)

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10
Q

leakage of urine by intra pressure the can occur when an individual laughs, sneezes, or coughs

A

Stress Urinary Incontinence

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11
Q

Involuntary passage of urine after a string sense of urgency to void

A

Urge Urinary Incontinence

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12
Q

Involuntary, unpredictable passage of urine despite the fact that the urinary tract is functioning efficiently

A

Functional Urinary Incontinence

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13
Q

Voluntary or involuntary loss of small amount of urine from an over distended bladder

A

Overflow Urinary Incontinence

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14
Q

Characteristics of Urinary Retention

A

Difficulty starting a stream or emptying the bladder
Weak urine flow
Chronic or cute pain

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15
Q

Factors that affect urinary elimination (8)

A 
age
gender
privacy issues
pathologic and surgical conditions
medications
food and fluid intake
ambulatory ability
muscle tone
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16
Q

Single most common hospital-acquired infection, caused from bacteria in the urine

A

Urinary Tract Infection

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17
Q

Which gender is more vulnerable to UTI?

A

Female

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18
Q

Who is at risk of UTI?

A

Women
Catheter patients
trouble voiding
elderly and bladder control loss

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19
Q

infection that causes Irritated bladder, causes urgent need to void

A

Cystitis

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20
Q

Kidney infection- flank pain, fever, chills

A

Pyelonephritis

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21
Q

Spread of organisms into the kidneys and blood

A

Urosepsis

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22
Q

Bringing the end of one or both ureters to the abdominal surface

A

Ureterostomy

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23
Q

Tube places directly into renal pelvis to provide urinary drainage

A

Nephrostomy

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24
Q

Adequate urine output

A

Catheterized- 30mL/hour

Voiding once per eight hours

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25
Q

dark yellow urine indicated?

A

dehydration

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26
Q

Fluorescent yellow/light orange colored urine indicates?

A

Excess B vitamins

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27
Q

Orange urine indicates

A

medications such as rifampin

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28
Q

Bloody urine indicates

A

Hematuria

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29
Q

Dark brown or dark orange urine indicates

A

jaundice, rhabdomyolysis

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30
Q

tea colored urine indicates

A

liver dysfunction

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31
Q

Dark amber urine indicates

A

high concentration of bilirubin causes by liver dysfunction

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32
Q

What does a sweet or fruity urine odor indicate?

A

acetone by product of Incomplete fat metabolism, diabetes or starvation.

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33
Q

How does one get stagnant urine?

A

Repeatedly incontinent and has an ammonia smell

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34
Q

How to get a urine culture and sensitivity

A

Clean-catch urine mid stream
used or a walking, talking patient.
Bed rest/confused/catheterized patient

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35
Q

BUN and Creatinine lab tests

A

Blood levels or urea and creatinine are used to evaluate renal function

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36
Q

KUB diagnostic tests

A

Kidney, Ureter, and Bladder X-Ray

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37
Q

Why insert an indwelling catheter

A 
Trauma
surgery
accurate I&O's
Decubitis ulcer 
physically unable to get OOB
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38
Q

Why insert a straight catheter?

A

urinary retention

urinalysis

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39
Q

Who enforces medication laws?

A

FDA

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40
Q

6 rights

A

right: medication, dose, client, route, time and documentation

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41
Q

before meal

A

AC, ac

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42
Q

twice a day

A

BID, bid

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43
Q

hour

A

H

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44
Q

at bedtime

A

HS, hs

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45
Q

after meal

A

PC, pc

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46
Q

whenever there is a need

A

prn

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47
Q

every morning, every am

A

Qam

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48
Q

every day, daily

A

QD

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49
Q

every hour

A

Qh

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50
Q

Every 2 hours

A

q2h

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51
Q

every 6 hours

A

q6h

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52
Q

4 times a day

A

QID, qid

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53
Q

every other day

A

QOD, qod

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54
Q

give immediately

A

STAT

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55
Q

3 times a day

A

TID, tid

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56
Q

Abbreviations not to use

A 
U for unit
IU for international unit
QD, QOD, QID; write daily, etc
Trailing zero (ex: 2.0)
MS04, MgSO4, MS ; write morphine sulfate, etc
u for micrograms
HS for half strength or bedtime
TIW for three times a week
DC for discharge
cc for cubic centimeter
AS, AD, AU (write left ear, right ear, etc)
OS, OD, OU (left eye, right eye, or both, etc)
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57
Q

an intestinal disorder that is characterized by an abnormal frequency and fluidity of fecal evacuations

A

Diarrhea

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58
Q

“C diff” bacterium causing diarrhea

A

Clostridium difficile

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59
Q

the loss of ability to voluntarily control fecal and gaseous discharges through the anus

A

Incontinence

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60
Q

infrequent or difficult bowel movements; fewer than three bowel movements per week

A

constipation

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61
Q

occurs when a persons breath is held while bearing down

A

Valsalva maneuver

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62
Q

hard fecal mass in the rectum or colon that the patient is incapable of expelling

A

Impactions

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63
Q

production of a mixture of gases in the intestine; byproducts of digestion

A

Flatulence

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64
Q

swollen and inflamed veins in the anus or lower rectum. Pregnant women and elderly are prone

A

Hemmorrhoids

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65
Q

the surgically created opening in the gastrointestinal, urinary, or respiratory organs, which is excited into the skin

A

Ostomy

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66
Q

surgically created when a portion of the colon or the rectum is removed and the remaining colon is brought through the abdominal wall

A

colostomy

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67
Q

Why do we change stony pouches?

A 
maintain skin integrity
access stoma healing and integrity
prevent odors
promote comfort
maintain or increase self-esteem and dignity
68
Q

What is a WOCN?

A

stony care nurse

69
Q

factors affecting bowel elimination

A 
position during defecation
pain
pregnancy
surgery and anesthesia
medications
diagnostic tests
70
Q

How to find out what is in stool

A

Fecal specimens

71
Q

how to find out if there is blood in stool

A

Fecal Occult

72
Q

Looks at upper GI tract (GI tract, esophagus, intestines, stomach, etc)

A

Upper GI Series Barium Swallow

73
Q

Enema with chalky white substance

A

Lower GI Series Barium Enema

74
Q

Camera is swallowed to view esophagus, small intestine

A

Upper Endoscopy (EGD)

75
Q

conscious sedation blow up with air

A

Colonoscopy

76
Q

safest enema, same osmotic pressure as fluids in interstitial space surrounding bowel

A

Saline Enema

77
Q

Enema that creates intestinal irritation to stimulate peristalsis, only pure castile soap is safe

A

Soapsuds Enema

78
Q

Enema that is hypotonic, escapes into interstitial spaces, volume stimulates defecation-never repeat due to fluid overload

A

Tap Water Enema

79
Q

Enema that exerts osmotic pressure that pulls out of interstitial space, colon fills with fluid and distention causes defecation-low volume needed

A

Hypertonic

80
Q

enema that lubricates the rectum and colon

A

Oil retention enema

81
Q

enemas containing medications such as antibiotics or Kayexalate for high K + levels

A

Medicated enemas

82
Q

solution is administered by enema and then drained to promote peristalsis and passing of flatus

A

Free-flow enema

83
Q

patient position for enemas

A

left sims position

84
Q

What is pitting edema associated with?

A

systemic problems, CHF, hepatic cirrhosis and local causes such as venous stasis.

85
Q

How to test for cranial nerve one

A

smell test

86
Q

how to test for cranial nerve two

A

snellen chart, newsprint

87
Q

how to test for cranial nerve three, four and six

A

PERRLA and positions test

88
Q

how to test for cranial nerve five

A

temporal and masseter muscle strength test, sensations on face test, and corneal reflex

89
Q

how to test cranial nerve seven

A

taste on anterior tongue, facial movements

90
Q

how to test cranial nerve eight

A

weber, rinne, and whisper test

91
Q

how to test cranial nerve nine and ten

A

gag reflex, swallowing, and soft palate/uvula rise

92
Q

how to test cranial nerve eleven

A

neck muscle strength, head turn, and shoulder shrug

93
Q

how to test cranial nerve twelve

A

tongue movements

94
Q

client opens eyes, answers questions, and falls back asleep

A

Lethargy

95
Q

client opens eyes to only voice, responds slowly with confusion, seems unaware of environment

A

obtunded

96
Q

client awakens to vigorous shake or painful stimuli but return to unresponsive sleep

A

stupor

97
Q

client remains unresponsive to all stimuli; eyes stay closed

A

coma

98
Q

How is Glascow Coma scale rated?

A

eye opening response (4, spontaneously)
most appropriate verbal response (5, oriented)
most integral motor response (6, obeys verbal command)

99
Q

slow repetitive speech is indicative of…?

A

depression or parkinsons

100
Q

loud, rapid speech and expression of elation and grandiosity may occur in manic phases of…?

A

bipolar disorder

101
Q

moving toward the midline of the body

A

adduction

102
Q

moving away from the midline of the body

A

abduction

103
Q

circular motion

A

circumduction

104
Q

moving outward

A

eversion

105
Q

straightening the extremity at the joint and increasing the angle of the joint

A

Extension

106
Q

bending the extremity of the joint and decreasing the angle of the joint

A

flexion

107
Q

turning or facing downward

A

pronation

108
Q

turning or facing upward

A

supination

109
Q

moving forward

A

protraction

110
Q

moving backward

A

retraction

111
Q

an exaggerated thoracic curve that is common with age

A

Kyphosis

112
Q

what can elbows do?

A

flex, extend, supinate

113
Q

what ca wrists do?

A

flex, extend, hyperextend, ulnar deviation and radial deviation

114
Q

what can fingers do?

A

abduct, adduct, flex, hyperextend

115
Q

what can hips do?

A

extend, flex, abduction, adduction, hyperextend

116
Q

what can knees do?

A

flex, extend, hyperextend

117
Q

what can toes do?

A

dorsiflexion, plantar flexion, eversion, inversion, abduction, adduction, flexion, extension

118
Q

What is IPPA?

A

Inspection, Palpate, Percuss, Auscultate

119
Q

Inspection of abdomen

A

Assess painful areas last
look across at eye level
Patient position: Dorsal Recumbent (Laying down with hands at sides)
Use four quadrants method

120
Q

What to inspect for on abdomen

A

scars and striae, pulsations, lesions and ecchymosis, venous patterning, drains tubes & stomas.

121
Q

Abnormal findings on abdomen inspection

A 
jaundice
Grey Turners Sign
ascites
Cullens Sign
deviated umbilicus
122
Q

significant abdominal swelling indicating fluid accumulation in the abdominal cavity

A

Ascites

123
Q

Purple discoloration at the flanks indicating bleeding within the abdominal wall

A

Grey Turners Sign

124
Q

bluish or purplish discoloration around umbilicus, indicates intra-abdominal bleeding

A

Cullens Sign

125
Q

major causes of abdominal distention (6 F’s)

A 
Fat
Flatulence
Feces
Fetus
Fluid
Fibroids
126
Q

How to auscultate abdomen

A

Begin in RLQ, proceed clockwise. Should hear soft clicks and gurgles.

127
Q

Abnormal findings of auscultating the abdomen

A

hypoactive bowel sounds- diminished bowel activity

The sound of Bruits- could indicate aneurism or arterial stenosis

128
Q

Palpation of abdomen:

A

Used to identify areas of tenderness and muscular resistance

Abdomen should be contender, soft, and no guarding

129
Q

Abnormal findings of palpation of abdomen

A

severe tenderness/pain- trauma, peritonitis, infection, tumors, enlarged or diseased organs.
Spasm, muscular rigidity, guarding
Distended bladder

130
Q

Percussion of Bladder :

A

Used to assess for tenderness in difficult to palate structures.
Normal: no tenderness
Percuss for tone.
Generalized tympany should be heard because of air in stomach and intestine.
Normal dullness heard over liver and spleen.

131
Q

Abnormal Finding of percussion

A

Tenderness or sharp pain elicited over costavertebral angels suggest kidney infection, renal calculi, or cyst in kidney

132
Q

Accenuated sharp pain that causes the client to hold his or her breath, can be indicative of cholecystitis

A

Murphys sign

133
Q

Landmarks of the abdomen

A 
Right costal margin
Rt. and Lf. Flank
Umbilicus
Anterior Superior Iliac Crest
Symphysis Pubis
134
Q

high pitched, harsh, or hollow quality sound. Amplitude- loud and short duration during inspiration, long in expiration. Located at trachea and anterior thorax

A

Bronchial breath sounds

135
Q

moderate pitch, mixed quality, moderate amplitude, duration is the same during inspiration and expiration, located over major bronchi

A

Bronchovesicular sounds

136
Q

low pitch, breezy quality, soft amplitude, duration is long on inspiration and short in expiration, located in peripheral lung field

A

Vesicular sounds

137
Q

low pitched, dry, grating sounds, much like crackles, only more superficial and occurring during both inspiration and expiration

A

Pleural friction rub

138
Q

low pitched snoring or moaning sound heard primarily during expiration, these may clear with cough

A

rhonchi (snores wheeze)

139
Q

high pitched, musical sounds heard primarily during expiration.

A

wheeze

140
Q

low pitched, bubbling, moist sounds, that persist from early inspiration to early expiration, velcro

A

Coarse Crackles

141
Q

high pitched, short popping sounds heard during inspiration and not cleared with coughing, sounds like rolling strand of hair

A

fine crackles

142
Q

tripod position commonly seen in what patients

A

COPD

143
Q

abnormal findings of respiratory assessment

A 
tachypnea
bradypnea
hyperventilation
hypoventilation
cheyenne- strokes
144
Q

vibrations of air in the bronchial tubes transmitted to the chest wall

A

fremitus

145
Q

Atrioventricular- located between the atrium and the ventricle

A

r- tricuspid

l- bicuspid

146
Q

semilunar- located at the exit of the ventricles and the beginning of the great vessels

A

r- pulmonic

l- aortic

147
Q

Where is S1 heard loudest?

A

mitral and tricuspid

148
Q

where is S2 heard loudest?

A

aortic and pulmonic

149
Q

S1 sound?

A

lub

150
Q

S2 sound?

A

dub

151
Q

why do extra heart sounds happen?

A

S3 and S4 are heard because ventricular vibration secondary to rapid ventricular filling.

152
Q

S3 sound

A

ventricle gallop- lub dub ta

153
Q

S4 sound

A

atrial gallop- ta lub dub

154
Q

What is S3 associated with?

A

CHF, myocardial failure, volume overload

155
Q

What is S4 associated with?

A

failing left ventricle, CAD, HTN, MI

156
Q

a swishing sound caused by turbulent blood flow through the heart valves or great vessels

A

Murmur

157
Q

this occurs when the ejection of blood into the aorta is turbulent, very common in children and young adults

A

Innocent murmur

158
Q

caused by temporary increase in blood flow, can occur with anemia, pregnancy, fever and hyperthyroidism

A

physiologic murmur

159
Q

caused by inflammation of there pericardial sac, is a high itched, scratchy, scraping sound

A

Pericardial friction rub

160
Q

sound commonly heard during the first week after a myocardial infarction

A

pericardial friction rub

161
Q

Indicates increased central venous pressure that may be the result of right ventricle failure, pulmonary hypertension, pulmonary emboli, or cardiac tamponade

A

Jugular Vein Distension

162
Q

palpable vibration that signifies turbulent blood flow

A

thrill

163
Q

blowing or swishing sound caused by turbulent blood through a narrowed vessel, is indicative of occlusive artery disease

A

bruit

164
Q

forceful thrusting of the ventricle during systole, occurs due to increased workload

A

heave or lift

165
Q

irregular heartbeat

A

arrhythmia or dysrhythmia

166
Q

indicates a weak contraction of the ventricles, and occurs with atrial fibrillation, premature beats, and CHF

A

pulse deficit

167
Q

how to palpate apical pulse

A

use one finger and palpate at 4th or 5th ICS, MCL on clients right side

Fundamentals- BSN1 (3 decks)

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