Exam 3 Study Guide Flashcards by Liz Seymour

pressure ulcer stage where skin is intact with nonblanchable redness

stage 1

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pressure ulcer stage where the wound is partial thickness and has gone through the epidermis and part of the dermis

stage 2

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pressure ulcer stage where the wound is full thickness through the epidermis, dermis, and part of SQ tissue

stage 3

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stage 3 pressure ulcers may have ________ drainage

serosanguinous

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pressure ulcer stage where the wound is full thickness down to the bone or muscle

stage 4

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stage 4 pressure ulcers may have ______ drainage

purulent

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3 things the PUSH tool assesses in pressure ulcer

length x width
exudate
tissue type

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ABCDEs of moles

asymmetry
border
color
diameter
evolving/elevation

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normal mole diameter

less than 1/4 inch (6 mm)

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lesions that are conjoined or running together

confluent lesion

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edema stage where there is slight pitting that rebounds immediately

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edema stage that is a bit deeper and takes about 15 seconds or less to rebound

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edema that pits noticeably deep and takes 15 to 20 seconds to rebound

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edema stage that pits very deep and takes longer than 20 seconds to rebound

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the primary function of the skin

protect the internal body

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vitamin produced by the skin

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6 categories of the Braden Scale

sensory perception
moisture
activity
mobility
nutrition
friction/shear

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score range for Braden Scale

6-23

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a score of __ or less on the Braden scale requires intervention

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inner ear infection

otitis media

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otitis media symptoms

red, bulging eardrum
diminished or absent light reflex
fluid or pus

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grade __ tonsils are visible

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grade __ tonsils are midway between tonsillar pillars and uvula

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grade __ tonsils are touching the uvula

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grade ___ tonsils are touching each other

lymph nodes in front of ear

preauricular

lymph nodes behind ear

posterior auricular

lymph nodes at base of skull

occipital

lymph nodes next to the carotid pulse

tonsillar

lymph nodes under the jaw

submandibular

lymph nodes under the chin

submental

lymph nodes above the collar bone

subclavicular

lymph nodes under the tonsillar lymph nodes

superficial clavicular

lymph nodes on the side of the neck

posterior cervical chain

lymph nodes on the front of the neck

deep cervical chain

pull pinna ____ and back for adults

pull pinna ____ and back for children

down

2 tests to do when you suspect hearing loss in one ear

Weber and Rinnes test

sound waves transmitted by middle and outer ear

conduction hearing

sound waves transmitted by inner ear

sensorineural

where to place the tuning fork in the Weber test

center or patients forehead

in the weber test, if the client reports sound lateralizing to the bad ear, then it is ________ hearing loss

conduction

in the weber test, is the client reports sound lateralizing to the good ear, then it is _______ hearing loss

sensorineural

in the Rinne test, place the base of the tuning fork at the ______ _____ and then the other end at the _____

mastoid process, ear

placing the tuning fork by the mastoid process in the Rinne test tests ______ conduction

bone

placing the tuning fork by the ear in the Rinne test tests _____ conduction

air

normal findings in Rinne test

AC greater than BC

if BC is greater than AC, then it is _______ hearing loss

conductive

OS abbreviation

left eye

OD abbreviation

right eye

damage to the ocular nerve because of high ocular pressure

glaucoma

glaucoma S/E

blind spots, tunnel vision, halos, blurred vision

gradual loss of vision caused by aging and thinning of the membrane on the retina

macular degeneration

condition where the vitreous pulls away from the retina and tears the retina

retinal detachment

retinal detachment causes ______

blindness

clouding and hardening of the lens

cataracts

cataracts S/E

cloudy vision, worse vision at night, fading yellow colors, light and glare sensitivity, halos

signs of hyperthyroidism

weight loss, increased HR, irritable, sweaty

signs of hypothyroidism

weight gain, cold, tired

overgrowth of facial hair on women

hirsutism

small lesion that is flat to skin and red, brown, or tan color

macule

small, solid, raised lesion that is purple or red in color

papule

small thinned walled, raised blister with drainage inside

vesicle

constant malalignment of the eyes

strabismus

an oscillating (shaking) movement of the eyes

nystagmus

difficulty swallowing

dysphagia

inverted lower eye lid

entropion

everted lower lid

ectropion

protrusion of the eyes

exopthalmos

loss of hearing due to age

presbycusis

large or swollen lymph nodes

adenopathy