Exam 3 Review

Question 1

What are 2 clinical manifestations for hypoxia?

Answer 1

Rapid pulse, rapid shallow breaths

Question 2

How are venous ulcers formed?

Answer 2

Decreased blood flow returning from the lower extremities to the heart.

Question 3

Symbolic satisfaction of wishes through nonrational thought

Answer 3

Fantasy

Question 4

Describe sanguineous exudate

Answer 4

Dark red drainage (red blood cells)

Question 5

What physiological changes occur to the heart valves as we age?

Answer 5

Calcification and thickening

Question 6

Discharging pent up feelings on people less dangerous than those who initially aroused the emotion

Answer 6

Displacement

Question 7

Tissue of a wound is reddish/ fragile, where would the culture be obtained

Answer 7

Granulation tissue

Question 8

How do you appropriately clean a wound?

Answer 8

Inside move out to avoid contamination

Question 9

Decrease in cardiovascular impacts of immobility may be obtained through ROM?

Answer 9

Dorsiflexion- reduce thrombus formation

Question 10

Name four types of debridement

Answer 10

Sharp
Mechanical
Chemical
Autolytic

Question 11

The purpose of placing SCDs on clients?

Answer 11

Enhance and promote venous blood return towards heart

Question 12

Where should the depth of a pressure ulcer be measured?

Answer 12

Deepest part of wound

Question 13

What portion is best for patients with dyspnea

Answer 13

High fowlers

Question 14

When do you see sanguineous exudate?

Answer 14

Fresh open wound

Question 15

Client refused medication or treatment, who do you notify?

Answer 15

Medical physician

Question 16

HTN is a modifiable risk factor for heart disease True/ False

Answer 16

True

Question 17

What is the purpose of floating heels?

Answer 17

To help prevent skin breakdown

Question 18

Handling emotional conflicts or internal or external stressors, by a temporary alteration or consciousness or identity

Answer 18

Dissociation

Question 19

Why isn’t heat therapy used in the first 24 hours of injury?

Answer 19

Because it increases inflammation and bleeding

Question 20

Freedom or independence of client exercise without external influence?

Answer 20

Autonomy

Question 21

Poor nutrition affects the skin integrity due to?

Answer 21

Decreased protein intake

Question 22

Your taste sensory is also called

Answer 22

Gustatory

Question 23

Where are diabetic ulcers found?

Answer 23

Tops of toes, feet and legs.

Question 24

What assessment can a nurse administer to assess level of cognition or confusion?

Answer 24

MMSE

Question 25

Medication that liquefies mucous allowing it to be easily coughed up

Answer 25

Expectorant

Question 26

Attempting to take back an unconscious thought or behavior that is unacceptable or hurtful

Answer 26

Undoing

Question 27

What is the minimal amount of exercise an individual should get?

Answer 27

30 min aerobic five times/ week

Question 28

BNP is a cardiac enzyme to test for what?

Answer 28

CHF-- (heart failure)

Question 29

Factors that significantly raise skin breakdown in patients?

Answer 29

Age, mobility, moisture, incontinence

Question 30

Dementia is an acute episode of confusion? True/ false?

Answer 30

False! Dementia is chronic, delirium is acute

Question 31

Where do you take a culture from an infection?

Answer 31

Granulation tissue

Question 32

Later in skin between muscle and adipose tissue

Answer 32

Fascia

Question 33

A method used to open collapsed aveoli and loosen secretions is called

Answer 33

Incentive spirometer

Question 34

Serum protein (protein in the blood) is nutritional reserve for?

Answer 34

Rebuilding cells

Question 35

What are some benefits for exercise for older adults?

Answer 35

Increased bone density, increased joint ROM

Question 36

Blocking out painful or anxiety-inducing events or feelings

Answer 36

Denial

Question 37

What clients most susceptible to sensory deprivation?

Answer 37

Solitary, bed ridden

Question 38

For wounds, can a upsilons be stitched?

Answer 38

No!

Question 39

Process of blocking out painful or anxiety inducing events or feelings is called?

Answer 39

Denial

Question 40

Is oxygen needed to heal wounds?

Answer 40

Yes

Question 41

If an area has excessive body heat what is the body trying to tell you?

Answer 41

That the area has an increase need for oxygen

Question 42

A wound that encompasses the epidermis and maybe some of dermis is what?

Answer 42

Stage 2 ulcer

Question 43

What finding suggests to the nurse the client is experiencing sensory overload?

Answer 43

Rage, insomnia, muscle tension, anxiety attack, seizure, isolation

Question 44

Common risk assessment scale for checking wound-healing status

Answer 44

Braden scale

Question 45

Unconscious assumption of similarity between oneself and another

Answer 45

Identification

Question 46

Acceptance of another's values and opinions as ones own

Answer 46

Introjection

Question 47

Cardiac enzyme used for MI patients?

Answer 47

Troponin

Question 48

What type of clients are at a greater risk for thrombus formation?

Answer 48

PVD, obese, smoker, and | sedentary lifestyles

Question 49

Reverting to an earlier stage of development

Answer 49

Regression

Question 50

What type of O2 delivery device puts out 95% oxygen to patient?

Answer 50

Non-breather face mask

Question 51

Serious respiratory impact from immobility?

Answer 51

Pneumonia, pooling respiratory secretions

Question 52

Describe albumin

Answer 52

Prolonged protein depletion

Question 53

Chronic illnesses that affect skin integrity

Answer 53

PVD, PAD, CAD

Question 54

What does REEDA stand for?

Answer 54

``` Redness Edema Ecchymosis Drainage Approximation ```

Question 55

What is REEDA used for?

Answer 55

Wound evaluation

Question 56

What is Santil?

Answer 56

A way of debriding dead tissue

Question 57

What is non-maleficence

Answer 57

Duty to cause no harm

Question 58

The dermis separates from underlying structures can be described as what type of wound?

Answer 58

Skin tear

Question 59

Significant difference between anxiety and fear?

Answer 59

Fear has identifiable source, anxiety does not

Question 60

Describe granulation tissue

Answer 60

Red healthy tissue with good circulation and profusion

Question 61

How do you measure a pressure ulcer?

Answer 61

With a sterile swab stick

Question 62

What is suppuration?

Answer 62

The formation of pus

Question 63

Charcots foot can occur from?

Answer 63

Neuropathy

Question 64

Describe venous ulcers

Answer 64

Wound drainage and irregular wound edges

Question 65

Stress can cause significant decrease in blood glucose levels. True/ False?

Answer 65

False

Question 66

What are some characteristics of diabetic ulcers?

Answer 66

Irregular wound margins and callous around the wound