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Final Exam Flashcards

1
Q

What does COLDSPA mean?

A

Character
Onset
Location
Duration
Pattern
Associated Factors

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2
Q

What does PQRST

A

Provactive; What provokes or relieves the pain

Quality; Character of the pain

Radiates; is pain local or radiates

Severity; Scale of 1-10

Timing; When does pain occur or how long does it last

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3
Q

What is the Nursing Process

A

Assessment
Diagnosis
Planning
Interventions
Evaluation

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4
Q

What are the developmental stages (Erikson)

A

Infant: Trust vs Mistrust

Toddler: Autonomy vs Shame/Doubt

Pre-schooler: Initiative vs Guilt

Grade-schooler: Industry vs Inferiority

Teenager: Identity vs Role Confusion

Young adult: Intimacy vs Isolation

Middle-age adult: Generatively vs Stagnation

Older adult: Integrity vs Despair

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5
Q

Special Considerations for Skin, Hair, & Nails (infants)

A

Lanugo; Fine hair

Vernix Caseosa; biofilm

Unregulated temperature

Underdeveloped eccrine glands

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6
Q

Special Considerations for Skin, Hair, & Nails (Pregnant Women)

A

Linea nigra: Line on stomach

Chloasma: brown spot on face

Stria gravidarum: stretch marks

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7
Q

Special Considerations for Skin, Hair, & Nails (Older adults)

A

Decreased sweat

Decreased flexibility & mobility

May have dryer skin

Decreased skin turgor resulting in sagging skin

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8
Q

How to assess skin turgor?

A

Using two fingers gently pinch skin over clavicle

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9
Q

What does decreased skin turgor indicate?

A

Dehydration

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10
Q

Definition of Pallor

A

Loss of color related to arterial insufficiency, decreased blood flow, or anemia

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11
Q

Definition of Cyanosis

A

Blue-tinged

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12
Q

Definition of Jaundice

A

Yellow skin tone usually in sclera, oral mucosa, palms or soles

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13
Q

Definition of Erythema

A

Skin redness/warmth related to inflammation, allergic reactions, or trauma

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14
Q

Skin Assessment (ABCDE)

A

Asymmetry
Border
Color
Diameter
Elevation/Enlargement

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15
Q

Pressure Ulcer Staging

A

STAGE I: Nonblanchable, skin is intact & red

STAGE II: Partial-thickness loss epidermis & some dermis

STAGE III: Full-thickness loss & necrosis of subQ tissue, tendon/bone are not exposed

STAGE IV: Full-thickness loss with muscle, bone or tendon visible

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16
Q

Special Consideration of Eyes (Older adults)

A

Pupil size decreases

Visual acuity may diminish

Lens loses elasticity resulting in decreased accommodation (Presbyopia)

Arcus senilis: White arc around limbus

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17
Q

How to test peripheral vision?

A

Perform confrontation test; Stand 2ft away and move finger into 3 visual fields

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18
Q

How to test pupillary reaction?

A

TURN LIGHTS OFF

Use penlight to check for bilateral consensual reflex

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19
Q

What CN are the eyes?

A

CN III, IV, VI

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20
Q

Describe a Sinus Headache

A

Constant throbbing pain that occurs w/ or after a cold. Worsens with sudden movements of the head & associated w/fevers, sinusitis, nasal drainage

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21
Q

Describe a Cluster Headache

A

Stabbing pain usually caused by ingesting alcohol and relieved by movement or walking back & forth.

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22
Q

Describe a Tension Headache

A

Dull or tight occurs with stress, anxiety or depression. Can last days, months, or years & relieved by message, heat or antidepressants.

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23
Q

Describe a Migraine Headache

A

Accompanied by nausea, vomiting & sensitivity to light. Can lasts up to 3 days and described as throbbing or severe pain. Rest may bring relief.

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24
Q

Describe crackles (fine) & associated

A

High pitched, short popping sounds cleared w/ coughing

Associated w/ asthma COPD conditions

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25
Describe crackles (coarse) & associated
Low pitched, moist bubbling sounds Associated w/pneumonia, pulmonary edema & pulmonary fibrosis
26
Describe Pleural friction rub
Low pitched grating sound occurs during inspiration and expiration Associated w/pleuritis
27
Describe Wheeze
High pitched musical sounds Associated w asthma & emphysema
28
Describe wheeze (sonorous)
Low pitched snoring or moaning sounds Associated w/bronchitis, obstruction or stridor
29
Smoking Cessation Mneumonic
Ask, advise, Assess, Assist, Arrange
30
Special Considerations for Cardio (Infants)
Heart beat begins 3 weeks gestation Oxygenation occurs via placenta Formen ovale closes within first hour (Ductus arterioles closes within 10-15 hours)
31
Special Considerations for Cardio (Pregnant women)
Increased blood volume 30-40% Increased SV & CO (pulse 10-15 bpm higher) Decreased arterial blood pressure Decreased BP drops during 2nd trimester, then increases back to normal
32
Special Considerations for Cardio (Older adults)
Systole BP (20 mm Hg) due to stiffening of large arteries Increased LV wall thickness Increased risk for arrhythmia & coronary artery disease Ectopic beats (extra heart beats) are common
33
Definition of Murmur
Blowing, swishing sounds over valve area or intercostal space (Described as musical, harsh, or rumbling)
34
Electrical Pathways of the heart
1.) SA node (sinus node) generates impulses & contracts to send blood to ventricles 2.) Impulse conducted to atria to AV node 3.) AV node relays impulse to AV bundle (bundle of His) 4.) Electrical impulses travel to right and left bundle branch & purkinje fibers in myocardium to both ventricles
35
Normal Heart Sounds & Where are they heard the best
S1 (“lub”)-Best at apex M1-mitral valve closure T1-Tricupsid valve closure S2 (“dub”)-Best at base A2-aortic valves closure P2-pulmonic valve closure
36
Why is systole split into two?
S1- Beginning of systole, closing of AV valves (tricuspid & mitral) S2-Ventricular emptying, decreased pressure & closing of semilunar valves (aortic & pulmonic)
37
Lays of the Heart & Function
Pericardium- Fibroserous sac that attache to great vessels & surround heart Myocardium-Thickest layer, contracts muscle cells Endocardium-Thin endothelial tissue & lines inner surface of heart
38
S/S of Arterial Insufficiency
Cold, pale (pallor), clammy skin, thin skin on extremities
39
S/S of Venous Insufficiency
Warm skin, edema, brown hyperpigmentation
40
S/S of Peripheral Venous Disease and Indicates
Heaviness of legs, aching aggravated by standing/sitting. leg edema Associated with delayed wound healing
41
What does Peripheral Venous Disease Cause?
Blood clots, DVT, swelling, narrowing/blockage of vessels
42
Assessment order for Abdomen
Inspection Auscultate Percuss Palpation
43
Organs in RUQ
Liver (majority) Gallbladder* Right kidney Pancreas (small portion) Transverse/ascending
44
Organs in LUQ
Liver (small portion) Spleen* Left kidney Pancreas (majority) Transverse/descending
45
Organs in RLQ
Appendix* Right ovary/fallopian tube Ascending colon
46
Organs in LLQ
Left ovary/fallopian tube Left ureter Sigmoid colon
47
Special Considerations for Musculoskeletal (Older adults)
Lost of bone density Joint stiffening conditions Osteoporosis; bones break down & become fragile
48
Why is the CAGE assessments & what do the questions include?
Four questions to assess alcohol dependence 1.) Cut down on your drinking 2.) Annoyed by people asking about your drinking 3.) Guilty about drinking 4.) Eye-opener in the morning to relieve shakes
49
Dementia vs Delirium
Dementia is a gradual progression w/changes in the brain & irreversible; Alzheimers. LOC unchanged & normal behavior Delirium is a sudden onset but temporary & reversible. LOC changed & disturbed behavior
50
In what order do adolescents develop? (female)
1.) Breast enlargement 2.) Hair growth 3.) Menstrual period
51
In what order do adolescents develop? (Males)
1.) Testicle enlargement 2.) Hair growth 3.) Height
52
How to perform Testicular Self-examination
1.) Palpate the testis 2.) Index & middle fingers to roll testis in horizontal plane to feel for lumps 3.) Begin to palpate upward 4.) Locate epididymis
53
How to perform Breast Self-examination
Use the pads of three fingers to palpate in a circular movement
54
How to grade Tonsils
1+: Tonsils are visible 2+ Tonsils are midway between pillar & uvula 3+ Tonsils touch uvula 4+ Tonsils touch each other
55
Name & Function of CN I
Olfactory; sense of smell
56
Name & Function of CN II
Optic; Visual impulses to brain
57
Name & Function of CN III
Oculomotor; Eye movement (Constriction of pupils)
58
Name & Function of CN IV
Trochlear; Extraoccular eye movements
59
Name & Function of CN V
Trigeminal; Controls impulses of pain, temperature, & pain to the brain -Controls jaw movements (chewing, biting)
60
Name & Function of CN VI
Abducens; Controls lateral eye movements
61
Name & Function of CN VII
Facial; Stimulates salvia & tears
62
Name & Function of CN VIII
Acoustic, vestibulocochlea; Hearing & balance
63
Name & Function of CN IX
Glossopharyngeal; Gag reflex
64
Name & Function of CN X
Vagus; Swallowing, talking, production of digestive juices
65
Name & Function of CN XI
Spinal accessory; Promotes movement of shoulder & head rotation
66
Name & Function of CN XII
Hypoglossal; Controls tongue movements
67
Define Kussmaul respirations
Rapid, deep or labored breathing, caused by diabetic ketoacidosis
68
Define Cheyne-Stokes respirations
Periods of deep rapid breathing followed by periods of apnea
69
Define Biot respirations
Irregular pattern characterized by varying rate of respirations followed by periods of apnea
70
Define Bronchial breath sounds (Normal)
Loud high pitched sound w/harsh or hollow quality. Short during inspiration & long during expirations located over the trachea & thorax
71
Define Bronchovesicular breath sounds (Normal)
Moderate pitch w/moderate quality. Same sound during inspiration & expiration located over bronchi-posterior & sternum
72
Define Vesicular breath sounds (Normal)
Soft low sound w/breezy quality. Long in inspiration short in expiration heard over peripheral lung fields

Health Assessment (5 decks)

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