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NURS123 > finisher > Flashcards

finisher Flashcards

1
Q

Describe Bristol Stool Chart

A

1 to 7, 1 indicating constipation, 7 indicating diahreeah

3 and 4 smooth and firm or lumpy and firm are healthy and normal

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2
Q

Organs contained w/i RUQ

A

liver, gallbladder, duodenum, head of pancreas, right kidney, hepatic flexure of colon, parts of ascending and transverse colon.

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3
Q

Organs contained in LUQ

A

stomach, spleen, left lobe of liver, body of pancreas, left kidney, splenic flexure of colon, parts of transverse and descending colo

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4
Q

Organs contained within RLQ

A

– cecum, appendix, right ovary and fallopian tube, right ureter, right spermatic cord.

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5
Q

Organs contained within LLQ`

A

part of descending colon, sigmoid colon, left ovary and fallopian tube, left ureter, left spermatic cord.

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6
Q

Where in the abdomenal wall can aorotic pulsations be felt?

A

the left upper anterior abdominal wall.

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7
Q

Where would liver referred pain appear

A

may produce dull pain in RUQ or epigastrium.

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8
Q

Esophagus referred pain

A

Gastroesophageal reflex disease (GERD) (“heartburn”).

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9
Q

Gallbladder refererd pain

A

cholecystitis is sudden pain in RUQ that may radiate to the right or left scapula.

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10
Q

Stomach referred pain

A

– gastric ulcer pain is dull, aching, or burning in epigastric region, often radiates to the back.

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11
Q

Appendix referred pain

A

starts as dull, diffuse pain in periumbilical region that later shifts to be localized in the RLQ.

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12
Q

Kidney referred pain

A

kidney stones produce a sudden onset of severe flank or lower abdominal pain

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13
Q

Older person factors in regards to GI system

A

Decreaed salivation, more prone to dehydration

Decreased renal function

Constipation

Food access, recall, emotionall characteristics

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14
Q

Some consideration before stomach examination

A

-Have patient empty bladder before exam
-Warm room
-Fully exposed abdomen - lift the gown and pull down the covers (genitalia and breasts remain covered)
-Ask about tender areas – palpate last
-Patients arms/hands at side and pt can bend knees slightly (or pillow beneath knees)

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15
Q

How long should bowel sounds b lsitended for if no soudns?

A

up to 5 minutes

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16
Q

Normal bowel sounds

A

5-30 times per minute

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17
Q

Percussion sounds

A

dullness is heard over solid organs, or over a distended bladder, tympany over air (air in peritoneal cavity rises to surface when pt is supine).

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18
Q

What is the percussion sound heard in a patient with gaseous distention

A

Hyper-resonance

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19
Q

During a physical exam of abdomen, what is the last step

A

Palpate last

  • Can cause tenderness, shift fluids, cause abnormal souneds
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20
Q

Correct order of avdomen assesssment

A

Inspection, asucultation, percussion, palpation

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21
Q

How is light abdomelan palpation done

A

Put four fingers together and gently press down into abdomen. Approx 1 cm. make gentle rotary motion and then pick up fingers and move to another location. Don’t drag.
Save the examination of any tender area of the abdomen for last.

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22
Q

Blumberg’s sign

A

Rebound tenderness during abdomen palpation

pain on release of pressure. Means peritoneal inflammation. And often appendicitis.

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23
Q

Murphy’s sign

A

Inspiratory arrest

liver or gallbladder pain. Hold fingers under the liver border and have patient take a deep breath. If pain at liver margins, then positive for liver or gallbladder inflammation

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24
Q

Iliopsoas muscle test

A

done when acute abdominal pain is suspect for appendicitis. With patient supine, lift the right leg straight up, flexing at the hip, and push down over the lower part of the right thigh as the patient tries to hold the leg up. With appendicitis – there is RLQ pain with this manouver. If no pain, it is negative.

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25
Q

Ascites

A

accumulation of protein-containing (ascitic) fluid within the abdomen

Most often due to high blood pressure in veins bringing blood to liver

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26
Q

Rectum

A

distal portion of the large intestine, extends from sigmoid colon to anal canal.

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27
Q

What are the two concentric layers of muscle in the anus

A

Sphincters

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28
Q

Main symptom of enlarged prsotate

A

Urinary frequency

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29
Q

Seminal vesicles

A

Produce sperm nourishing fluid

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30
Q

What part of GI tract do diseases like Crohns, IBD, and celiac affect

A

Sigmoid colon

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31
Q

Third most common cancer in Canadians

A

Colorectal cancer

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32
Q

Corona

A

Proximal portion of glans

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33
Q

Dysuria

A

Pain or burning with urniation

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34
Q

Older adult GU consideratinos

A

Prostate enlargement
Incontinence
Nocturia
Sexual function

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35
Q

Frenulum

A

Bottom middle portion of V

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36
Q

Gravida

A

Number of pregnanciesP

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37
Q

Para

A

Number of births

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38
Q

Most commonly reported STI in Canada

A

Chlamydia

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39
Q

Normal urine output per day

A

30ml/h 1500ml/day

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40
Q

Signs of fluid overload

A

Weight gain
Pitting edema
Increased BP

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41
Q

Assessing for dehydration

A

Low BP
Fainting
BLoated stomach
Sunken dry eys
Skin looks wrinkled/lack of firmness
Lack of skin elasticity

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42
Q

Urinary retention

A

Unavble to void greater than 6-8 hrs

moderately distended bladder = 200-250ml

Urinary catherterization must be performed to releive retiention

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43
Q

How many Canadians expereience a disagnosised mental health crisis in their lifetime?

A

20%

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44
Q

Leading cause of disability worldwide?

A

Depression

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45
Q

Do sympotoms of depression always indicate a disorder?

A

No

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46
Q

Define mental health

A

The capacity of each and all of us to feel, think, act in ways that enhance our ability to enjoy life and deal with the challenges we face” (Public Health Agency of Canada).

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47
Q

Characteristics of mental health

A

Balance in all aspects of life as well as devloping resilience flexibility and self actualization

48
Q

Mental disorder

A

medical term for mental illness and is diagnosed in Canada based on the criteria set by Diagnosis and Statistical Manual of Mental Disorder, fifth ed (DSM-5)

49
Q

Is there comorbidity bw chronic physical conditions and mental health?

A

Yes

50
Q

Aspects of a mental health nursing assessment

A

Observation
Interview
Exam
Physical Assessment
Collaboration with others

51
Q

What indicates need for comprehensive mental health nursing assessment

A

Behaviour changes, LOC changes, symptoms of depression, anxiety, ADHD, and substance use

52
Q

Leading cause of death for Canadian teens 15-19

A

Suicide

53
Q

What aspects are evaluated in functional mental health assessment

A

Self concept/esteem
Interpersonal relationships and resources
Coping/strwss management

54
Q

Domains of a mental status examination

A

A - Apperance

B - Behaviour (mood and affect, speech)

C - Cognition (Consiocusness, orientation, memory, attention etc.)

T - Thinking (Perception, content, process, judgement)

55
Q

Objective data for behaviour

A

LOC

A&O x 3

56
Q

Objective data for assessing a patients mental awareness

A

Thought process (do they make sense/logical)

Thought content

Perceptions (delusions)

57
Q

What is screened for in a mental health risk assessment

A

Suicidal thoughts
Assault or homicidal ideation
Elopement Risk

58
Q

Montreal Cognitive Assessment useful

A

For dection dementia and delirium apart from a psychiatric mental illness

59
Q

4 areas influencing substance use

A

Social practices/acceptibilty
Affordability
Issues of trauma, viorlence, and chronic pain
Mental health link

60
Q

Substance use isn’t the problem but

A

A symptom of other pre-existing problems

61
Q

Addiction vs dependence

A

Addiction: Generally refers to compuslion and dependse; disagreement over usefulness of term

Dependence: Label for compuslive, out of control substance use

62
Q

How to document substance use

A

Type of substance used
Amount(s)
Route
Result of HH and physical assessment

63
Q

TWEAK screening

A

Used for identifying women at risk for alcohol use problems

Tolerance (How many drinks till you feel the effect)
Worry (Has anyone expressed worry abt your drinking)
Eyeopener (Do you drinkn in the morning when you wake up)
Amnesia (Do you seem forgetful)
(K)cut down (Do you feel the need to cut down?)

64
Q

CAGE questionaire

A

Cutdown (Have you felt the need?)
Annoyed (Have you been annoyed by people critisiing your drinking?)
Guilty (Have you felt)
Eye-opener (Have you had a drink in the morning)

2 or more yes responses are at risk for alcohol withdrawal

Test for alcohol abuse and dependence

Four straight forward questions with yes or no responses

  • Initiates conversation abt alcohol use
65
Q

Alcohol withdrawal symptoms

A

Insomnia, sweating, racing heart, tremors, nausea and vomiting, psychomotor agitation, anxiety, seizures (rarely hallucinations and perceptual disturbances). Can be life-threatening if not treated (cardiovascular collapse).

66
Q

Sedative withdrawal symptoms

A

anxiety, orthostatic hypotension, tremors of the hands, tongue and eyelids

67
Q

Nicotine withdrawal

A

vasodilation, headaches, irritability and nervousness,

68
Q

Cannabis withdrawal symptoms

A

irritability, nervousness, sleep difficulty, decreased appetite, restlessness, depressed mood and physical symptoms such as discomfort.

69
Q

Cocaine, amohetamines, and opiates withdrawal symptoms

A

dysphoric mood, agitation, insomnia, or hyper somnia

70
Q

COWS scale

A

Clinical Opiate Withdrawal Scale

71
Q

5 As for integrating knowledge of substance use into assessment

A

Aquire Knowledge
Anticipate harm that you could cause from practice, reactions, judgements
Analyze clinical assessment tools
Avoid social judgement
Approach patients respectfully

72
Q

IPV

A

Interpersonal violence

73
Q

IPV is

A

An abuse of power
Physical, sexual psychological, finacnial etc.

74
Q

Up to _____ of all women have expeeinced some form of abuse

A

50%

75
Q

4 risk factors in the ecological framework with IPV

A

Individual
Relationship
Community
Societal

76
Q

Best way to breach IPV qs with men

A

Broad Qs abt children and how things are at home

77
Q

Steps for assessing for intimate partner violence

A

Listen
Inquire
Validate
Enhance Safety
Support (Ongoing)

78
Q

How is trauma-and-violence-informed care done?

A

Creating environemnt safe for people facing(ed) violence NOT focused on disclosing circumstances or victimization

79
Q

TYpe of abuse more unique to elders?

A

Neglect, finanical or material exploitation

80
Q

Pareital pleura

A

lines chest cavity (pleural space) with lubricating fluid so lungs can move up and down. If filled with air or more fluid, compromises lung expansion (collects particularly in the costodiaphragmatic recess).

81
Q

Acinus

A

– a unit that contains bronchioles, alveolar ducts, alveolar sacs, and alveoli – for gas exchange (perfusion).

82
Q

How many lobes in lungs

A

R lung has 3
L lung has 2

83
Q

Barrel Chest

A

Increased AP (anteroposterior) diameter

84
Q

. Normal ratio of AP diameter to transverse diameter is

A

1:2

85
Q

Various shapes of chest

A

Barrel chest
Scoliosis
Kyphosis

86
Q

Tripoding

A

leaning foraward on elbows support breathing

87
Q

Pursed lip breathing

A
  • prolongs the expiratory phase for those people with CO2 trapping.
88
Q

tachypnea

A
  • increased resp rate
89
Q

Assessment triagnel

A

Work of breathing
Circulation to skin
Appearance

90
Q

Types of adventitious lung soiunds

A

Crackles- high pitched, short crackling popping sounds heard during inspiration that are not cleared by coughing. Commonly heard with congestive heart failure, pneumonia.

Pleural friction rub- superficial sound that is course and low pitched. It has a grating quality like to pieces of leather being rubbed together. Sound is both inspiratory and expiratory. Commonly heard in pleuritis.

Wheeze-high pitched musical squeaking sounds that occur usually on expiration but can occur on both inspiration and expiration. Commonly heard with asthma.
Stridor- loud, harsh high pitched inspiratory crowing sound commonly heard with croup (swollen larynx and/or trachea) in children.

91
Q

Pulmonary Function Tests (PFTs

A

– the number of seconds it takes for the patient to exhale from total lung capacity to residule volume; a screening for airflow obstructions. Takes a deep breath a blows out forcefully (normal time for full expiration is 4 sec or less) – can be auscultated with stethoscope over sternum or a handheld spirometer.

92
Q

5 components that make up spirituality

A

Purpose/Meaning
Values/Beliefs
Connectedness
Becoming
Transcendence

93
Q

Spiritual assessment framework

A

F Faith and belief
I importance and influence
C Community (do they support you)
A Address in care

94
Q

What is important to consider with spiritual care

A

Nurses should use caution when attempting to address the meaning-making of suffering

Be present for patients in their suffering
Treat pain and other negative symptoms
Provide a hospitable climate for those who are most important in patients’ lives

95
Q

Myalgia

A

Muscle pain (Felt as cramping or aching)

96
Q

Articular

A

Inside the joint capsule (i.e arthritis is an articular disease)

97
Q

Crepitation

A

audible and palpable crunching or grating sound that accompanies movement in the joint.

98
Q

Extra-articular

A

tendon, ligament, nerve around a joint.

99
Q

Contracture

A

= shortening of a muscle leading to limited ROM of joint.

100
Q

Ankylosis

A

Stiffness or fixation of joint

101
Q

Dislocation

A

One or more bones in a joint being out of position

102
Q

A screening of MSK system includes

A

Inspection and palpation of joints
Comparing bilateral joints
Observation of ROM
Age specific screeninging measures (osteoperosis)

103
Q

How does CWMS apply to the MSK system?

A

After injury or cast the CWMS is cecked to ensure arteriole blood flow

104
Q

Muscle stregth grading

A

0-5 (5 = full ROM against gravity, no resistance)

105
Q

Compartment syndrome

A

When pressure in the muscle builds to dangerous levels

106
Q

Parasthesia

A

Numbness

107
Q

5 Ps to check for compartment syndrome

A

Pain
Pallor
Parasthesia
Paralysis
Pulselessness

108
Q

NVAx

A

Peripheral neurovascular assessment

109
Q

Common walking abnormality

A

Propulsive (leaning forward) - parkinsons

Scissor’s gait
- Cerebral Palsy

Steppage gait
- foot drop

Hemiplegia - dragging a limb

110
Q

Can you move a pt who has fallen by yourself?

A

No

111
Q

KATZ tool is used for assesssing

A

INdividuals level of independecce for ADLs

112
Q

Apnea is classified as

A

Not breathing for 20 seconds or more

113
Q

Quality of the pulse is a reflection of

A

how well-perfused an individual is. Weak, thready pulses indicate poor perfusion.

114
Q

What is the first step if an abnormal BP is taken

A

Retake pts BP

115
Q

CBC

A

Complete blood count

) measures the size, number, and maturity of the different blood cells in a specific volume of blood. This is one of the most common tests performed

The hemoglobin portion of the CBC measures the oxygen carrying capacity of the red blood cells while the hematocrit measures the percentage of red blood cells in the blood.

116
Q
A

NURS123 (13 decks)

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