Final exam Flashcards
(158 cards)
1
Q
the exchange of blood, gases, and fluids between the vessels and tissues and organ systems
A
perfusion
2
Q
- Detect a weak peripheral pulse
- Measure a low blood pressure
- Magnifies pulsatile sounds
A
Doppler Ultrasonic stethoscope
3
Q
• Elastic stockings
• Aid in maintaining external pressure on the muscles of lower extremities to promote venous return
• Measure calf for correct size
*prevents edema, fluid pulling down on ankles
A
Thromboembolic device (TED’s)
4
Q
• Alternately inflates (10-15 sec) and deflates (45-60 sec)
• Decreases venous stasis by increasing venous return through deep veins of the legs
*helps prevent blood clots
A
Sequential compression device (SCD’s)
5
Q
Which pulses do we check on a regular basis?
A
- apical
- radial
- dorsalis pedis
6
Q
• Inspect the client’s neck while patient is at a 30-45 degree angle, pt in supine position
*turn head slightly
A
Jugular Venous Distension (JVD)
7
Q
• Palpate only one at a time to avoid compromising arterial blood to brain
• Auscultate each for the presence
of a bruit
A
carotid artery
8
Q
blowing, swishing sound indicating blood flow
turbulence. Normally, there is none
A
bruit
9
Q
What do you inspect of the extremities?
A
• Color: Pallor, erythema, cyanotic, mottled • Moisture: Moist, Dry • Nail beds: Color, Capillary refill - normal is <3 seconds • Temperature: Warm, Cool
10
Q
4+ on a four-point scale for palpating pulses represents
A
bounding
11
Q
3+ on a four-point scale for palpating pulses represents
A
full pulse, increased
12
Q
2+ on a four-point scale for palpating pulses represents
A
expected/normal
13
Q
1+ on a four-point scale for palpating pulses represents
A
diminished, barely palpable
14
Q
0 on a four-point scale for palpating pulses represents
A
absent
15
Q
first heart sound
systole
louder at apex
coincides with carotid pulse
A
S1-mitral, tricuspid
16
Q
second heart sound diastole louder at base • Creates the lub-dub sound • Note normal rate and rhythm
A
S2- aortic, pulmonic valves
17
Q
factors affecting respiration include:
A
- Lifestyle
- Medications
- Age
- Body weight
- Environment
- Health status
18
Q
Ventilation in excess of that required to eliminate carbon dioxide produced by cellular
metabolism
A
hyperventilation
19
Q
Alveolar ventilation inadequate to meet the body’s oxygen demand or to eliminate sufficient carbon dioxide
A
hypoventilation
20
Q
Inadequate tissue oxygenation at the cellular level
A
hypoxia
21
Q
Blue discoloration of the skin and mucous membranes
A
cyanosis
22
Q
what are the steps in oxygenation?
A
- ventilation
- perfusion
- diffusion
23
Q
The process of moving gases into and out of the lungs
A
ventilation
24
Q
The ability of the cardiovascular system to pump oxygenated blood to the tissues and return deoxygenated blood to the lungs
A
perfusion
25
Exchange of respiratory gases in the alveoli and capillaries
diffusion
26
average respiratory rate for infants?
About 30 breaths per minute
27
average respiratory rate for children (preschoolers)
About 25 breaths per minute
28
average respiratory rate for adults?
About 12-20 breaths per minute
29
Decreased level of oxygen in the blood
hypoxemia
30
Deficiency in amount of oxygen reaching the tissues
hypoxia
31
First signs of hypoxia may include…
* Anxiety
* Restlessness
* Confusion
32
Late sign of hypoxemia and is seen as a
| blue tinge to the skin
cyanosis
33
This condition is a chronic condition of oxygen deficiency and is irreversible.
clubbing
34
greater than 24, abnormally rapid
tachypnea
35
less than 10 breaths per minute, abnormally slow
bradypnea
36
lack of respiration for greater than 15 seconds
apnea
37
Abnormally deep, regular, and increased in rate;
kussmaul's
38
Variable pattern, rate & depth irregular
Cheyne-Stokes
39
Normal breath sounds include?
* bronchial
* bronchovesicular
* vesicular
40
(tracheal) Loud, harsh, hollow, tubular, high pitched breath sound
bronchial
41
(over larger bronchi) Blowing sounds, medium pitched breath sounds
bronchovesicular
42
(peripheral lung fields) Soft, breezy, low pitched breath sounds
• Easy auscultation
vesicular
43
* a type of adventitious sound, is not pathologic; short, popping, crackling sounds that sounds like fine crackles but do not last beyond a few breaths
* heard only in periphery and disappear after first few breaths or after a cough
atelectatic crackles
44
(rales) crackling sounds, may be fine, medium, or coarse
crackles
45
high-pitched, musical
wheezes
46
(gurgles) loud low-pitched, coarse, rumbling, during inspiration & expiration
rhonchi
47
dry, grating sounds as the pleural cavity is rubbing against
pleural friction rub
48
* Delivers 40-70% oxygen
* Minimum flow rate 6-10L/minute
* Adjust flow rate so that bag doesn’t collapse
* Approximately 1/3 of exhaled air goes back into bag
partial (non-rebreather)
49
* Delivers 60-80% oxygen
* Has one–way valve that keeps air from entering reservoir bag
* Adjust liter flow so that reservoir bag does not collapse more than ½ during each inspiration
non-breather
50
Helps prevent atelectasis and sleep apnea.
CPAP (Continuous Positive Airway Pressure) and
| BiPAP (Bi-level Positive Airway Pressure)
51
discontinuous abnormal lung sounds include?
* Crackles—fine
* Crackles—course
* Atelectatic crackles
* Pleural friction rub
52
continuous abnormal breath sounds include
* Wheeze—sibilant
* Wheeze—sonorous rhonchi
* Stridor
53
Disorders caused by which deficiency are among the leading causes of illness and death in the United States
nutritional
54
what nutritional assessments can be performed?
Anthropometric Measurements
Biochemical Analysis
Clinical Examination
Dietary Evaluation
55
```
Noninvasive techniques that quantify body dimensions
• Height
• Weight
• Waist, Arm and Head Circumference
• Skin Fold Thickness
```
anthropmetric measurements
56
Marker of healthy weight to body height
| Indicator of malnutrition or obesity
Body mass index
57
Classifications of BMI:
| for Underweight – below
below 18.5
58
Classifications of BMI:
| for Normal weight –
18.5-24.9
59
Classifications of BMI:
| for Overweight
25-29.9
60
Classifications of BMI:
| for Obesity –
BMI of 30 or greater
61
Indicates skeletal muscle mass and fat
stores
Measure in Centimeters
Compare measurement with standards
circumference
62
what factors influence nutrition?
```
Nitrogen balance
Hospitalization
Physical problems or limitations
Limited fixed incomes
Medications
```
63
What are the causes of distention (5 F's)?
```
5 F’s
• Fat
• Fluid
• Flatus
• Fetus
• Fibroids
```
64
the physical and chemical processes by which the body builds and maintains itself through anabolism and
catabolism
metabolism
65
hypothyroididm leads to a decrease in?
appetite
66
hyperthyroidism leads to an increase?
appetite
67
weak, shakey, hungry, jittery, sweaty. – late confusion,
| seizures
hypoglycemia
68
– polyuria, thirst, drowsiness, also hungry, Fruity
| breath
hyperglycemia
69
the removal of fluids and wastes from the body
Bowel
Urinary
elimination
70
1-2 sounds within 2 minutes
hypoactive bowel sounds
71
• 5-6 sounds heard in less than 30 seconds
hyperactive bowel sounds
72
a rumbling or gurgling noise made by the movement of fluid and gas in the intestines.
borborygmi
73
dull percussion can include?
* Mass
* Bone
* Enlarged liver
* Distended bladder
* Ascites (lateral)
74
tympany percussion can include?
* Air = Gas
* Air = Distention
* Air = Pregnancy
* Ascites (medial)
75
indicate excessive air in the chest
tympany
76
sounds heard over solid areas like bone
dull
77
labs related to GI elimination include
Total bilirubin:
Alkaline phosphatase:
Amylase:
Carcinoembryonic antigen (CEA):
78
total bilirubin should be
0.3-1mg/dl
79
alkaline phosphatase should be
30-120 units/dl
80
amylase labs should be
60-120 somogyi units/dl
81
carcinoembryonic antigen (CEA) labs should be
<5ng/ml
82
* “a state of complete physical, mental, social well-being, not merely the absence of disease or infirmity” (WHO, 1948)
* Individual variability
* A dynamic state of being in which the developmental and behavioral potential is realized to the fullest extent possible (ANA, 1980)
* Not just the absence of illness.
health
83
The process of equipping people to have control over, and to improve physical, emotional, and social health.
health promotion
84
A way of life- a life style you design to achieve your highest level of potential for well-being
A process- a developing awareness that there is no end point, but that health and happiness are possible in each moment here and now.
Loving acceptance of yourself
A dynamic balance of physical, psychological, social, and spiritual aspects of a person’s life
wellness
85
the components of health & wellness include
* The ability to perform at one’s best
* The ability to adapt
* A reported feeling of “being well”
* A feeling that everything is together and harmonious
86
what are the components of health promotion?
* self responsibility
* stress reduction and managements
* physical fitness
* nutritional awareness
87
internal variable factors influencing health
Biological
Psychological
Cognitive
Spiritual
88
external variable factors influencing health
Environment
Cultural beliefs
Standards of Living
Social support networks
89
* Looks at the relationship between a person’s beliefs and behaviors.
* Predicts how patients will behave in relation to their health and how they will comply with health care therapies.
* The likelihood that a person will take the recommended preventive health action depends on the perceived benefits of the action minus the perceived barriers to the action.
health belief model
90
■ Describes the multidimensional nature of persons as
they interact within their environment to pursue health.
■ A persons unique characteristics and experiences have an impact on their actions and motivation to pursue health promoting behaviors.
pender's health promotion model
91
• Incorporates the interaction of mind, body, and spirit into care
• Holistic Strategies:
Music therapy, relaxation therapy, therapeutic touch, massage, guided imagery, meditation and prayer.
Complementary and Alternative medicines (CAM therapy) play a role.
holistic health model
92
provide basics: feeding, IV, rest, medications, oxygen,
| etc.
Physiological Needs
93
side rails, assist OOB, call bell in reach, assist with
| needs of security
Safety & Security –
94
develop a therapeutic rapport, include family,
| encourage peers and visitors
Love & belonging
95
allow control, offer choices, accept client values
Self-esteem
96
adult learner principles, active listening style
Self-Actualization
97
activities are intended to motivate a person
toward the goal of a higher level of health and wellness
*passive
*active strategies
health promotion activities
98
obtain benefit through the intervention of others.
• Government interventions
• Primary health care
passive strategies
99
actively seek out and adopt
• Regular exercise and fitness
activities
active strategies
100
active changes include?
* Weight reduction
* Smoking cessation
* Nutrition
* Exercise
101
passive changes include?
* Fortified milks and cereals
* Fluoride in drinking water
* Trans fat bans
* GMO debates
102
what are the stages of change?
a. Pre-contemplation
b. Contemplation
c. Preparation
d. Action
e. Maintenance
103
no intention to take action in next 6 months
pre-contemplation
104
intends to take action in next 6 months
contemplation
105
intends to take action within next 30 days
preparation
106
has changed overt behavior for less than 6 months
action
107
has changed overt behavior for more than 6 months
maintenance
108
what are the four broad goals for healthy people 2020?
* Increase quality and years of healthy life
* Eliminate health disparities
* Create environments that promote health
* Promote healthy behaviors
109
a group of diverse medical and health care systems,
| practices, and products that are not generally considered part of conventional medicine
a group of complementary and alternative medicine
110
what is the leading cause of death in adolescents?
accidents
111
what is the leading cause of death in young adults?
violence
112
what are the common problems seen in middle aged adults?
anxiety and depression
113
increased lumbar curvature-arched back
lordosis
114
hunchback-exaggeration of posterior curvature of thoracic spine
kyphosis
115
lateral spinal curvature
scoliosis
116
patient can perform ROM on their own
active ROM
117
you completely do the ROM activities for the patient
passive ROM
118
The patient stands with unilateral weakness on the affected side, arm flexed, adducted and internally rotated
hemiplegic gait
119
typically defined as the presence of abnormal, uncoordinated movements
ataxic gait
120
Encompasses all the functions cells carry out to
maintain homeostasis, in particular their responses
to extracellular signals & how they produce an
intracellular response
cellular regulation
121
what are the leading causes of death for men?
lung, prostate, and colorectal
122
what are the leading causes of death for women?
lung, breast, and colorectal
123
secondary prevention for women include?
```
• Breast self awareness
• Breast self exam (BSE)
• Clinical breast exam
(CBE)
• Mammograms
• Pap smears
```
124
secondary prevention for men include?
* Prostate exam
| * Testicular exam
125
mammograms should start after what age?
40
126
most common cancer in men?
prostate/testicular cancer
127
Additional diagnostic tests and screenings for
| both men and women include:
* Sigmoidoscopy
* Colonoscopy
* Skin Survey
128
Carcinoembryonic antigen is a good indicator for which types of cancer?
breast, lung, liver, pancreas, stomach, ovaries, and thyroid cancer
129
Cancer antigen 125 is a good early indicator for which type of cancer?
ovarian
130
Neutralize, eliminate, or destroy invaders to our internal
| environment
immune response
131
the processes by which the nervous system
| activates, coordinates and controls the functions of the body
neural regulation
132
what is anisocoria?
unequal pupills
133
15/15 on the glasgow coma scale indicates?
fully alert and normal
134
score of 7/15 or less on the glasgow coma scale reflects?
coma
135
the worst score possible on the glasgow coma scale is?
3/15
136
drifts off to sleep when not stimulated; arousable but looks drowsy; responds appropriately but slowly; loses train of though
lethargic
137
difficult to arouse (needs loud shout or shake); confused when aroused; monosyllable answers; mumbles; constant stimulation
needed
obtunded
138
spontaneously unconscious; responds to persistent, vigorous shake or pain; appropriate motor response; only groans or moves restlessly; reflexes intact
stupor
139
unconscious; no response to stimuli; no purposeful movement
coma
140
dulled cognition; impaired alertness;
| disoriented, may hallucinate; often agitated
acute confusional state (delirium)
141
Tandem walking is?
heel to toe
142
stand up with feet together and arms at sides; close eyes and hold position; wait 20 seconds; slight sway normal
romberg test
143
decreased pain sensation
hypoalgesia
144
absent pain sensation
analgesia
145
increased pain sensation
hyperalgesia
146
partial or incomplete paralysis (weakness)
paresis
147
loss of motor function
paralysis
148
inability to control ROM of muscles (incoordination)
dysmetria
149
abnormal sensation (numbness, tingling)
parethesia
150
difficulty forming words
Dysarthria
151
difficulty with language comprehension or expression
dysphasia
152
a quivering movement of the eye.
nystagmus
153
measures the percentage of whole blood
| that is made up of red blood cells.
hematocrit
154
is produced as a product of protein metabolism and excreted through the kidneys.
Blood Urea Nitrogen (BUN)
155
urine becomes more concentrated as body tries to compensate for fluid losses. Normal urine specific gravity is 1.003-1.030
Urine specific gravity and osmolality
156
Plasma protein which helps hold the intravascular volume in the vascular space.
Serum Albumin(3.5-5.5g/dL)
157
• rate
• depth
• When accompanied by acidosis (Kussmaul
breathing) – deep and rapid
fluid deficit
158
```
• rate
• shallow respirations
• dyspnea increases with
exertion or in the supine
position
• moist crackles present on
auscultation
```
fluid excess
