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Nursing 1213 > Midterm 1 > Flashcards

Midterm 1 Flashcards

1
Q

What is the role of CFAM?

A

Enables nurses to complete a comprehensive examiniation of both an individual and family

Uses tools such as the genorgram and ecomap to explore the family

Provides structure and questions (areas and types)

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2
Q

What are the 3 main categories in the CFAM assessment?

A

Structural, Developmental, Functional

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3
Q

What are the 3 subcategories of the Structural component of the family assessment?

A

Internal, External, Context

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4
Q

What are the 3 subcategories of the Developmental component of the family assessment?

A

Stages, tasks and attachments

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5
Q

What are the 2 subcategories of the Functional component of the family assessment?

A

Instrumental and Expressive

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6
Q

What are 6 subcategories of the Internal Structure component of the family assessment?

A

Family composition, gender, sexual orientation, rank order, subsystems, boundaries

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7
Q

What are the 2 subcategories of the External Structure component of the family assessment?

A

Extended Family, Larger Subsystems

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8
Q

What are the 5 subcategories of the Context component of the family assessment?

A

Ethnicity, Race, Social class, Religion/Spirituality, Environment

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9
Q

What are the 6 Developmental Stages?

A
  1. Leaving home: Single Young Adults
  2. The new couple- marriage
  3. Families with Young Children
  4. Families with adolescents
  5. Launching children & moving on
  6. Families in later life
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10
Q

What are the tasks for: Leaving home: Single Young adults

A

Accepting financial and emotional responsibility for self

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11
Q

What are the tasks for: The new couple- marriage

A

Commitment to a new system

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12
Q

What are the tasks for: Families with Young Children

A

Accepting new members into system

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13
Q

What are the tasks for: Families with Adolescents

A

Increasing flexibility of family boundaries to include children’s independence and grandparents frailties

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14
Q

What are the tasks for: Launching children and moving on

A

Accepting a multitude of exits/entries into/from the family

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15
Q

What are the tasks for: Families later in life

A

Accepting the shifting of generational roles

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16
Q

___ x _____ = Cardiac output

A

Stroke volume, Heart Rate

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17
Q

What are the 4 factors affecting stroke volume?

A

preload, afterload, compliance, contractility

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18
Q

What does the JVP measure?

A

Indirect measure of central venous pressure ( pressure of blood in the thoracic vena cava, near the R atrium of the heart)

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19
Q

During Cardiac exam: Palpate…

A

Carotid pulse, Apical impulse, heaves, thrills

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20
Q

T/F: Palpate carotid arteries one at a time

A

TRUE!!!

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21
Q

How do you palpate parasternal heaves?

A

Vertical hand between nipples

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22
Q

How do you palpate thrills?

A

horizontal hand on chest

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23
Q

S1 occurs when….

A

Atrioventricular valves close

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24
Q

S2 occurs when…

A

Semilunar valves close

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25
Q

Auscultation: What does APETM stand for?

A

Aortic, pulmonic, Erb’s point, Tricuspid, Mitral

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26
Q

Where should auscultation of Aortic area take place?

A

Right side, 2nd intercostal space

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27
Q

Where should auscultation of Pulmonic area take place?

A

Left side, 2nd intercostal space

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28
Q

Where should auscultation of Erb’s point take place?

A

Left side, 3rd intercostal space

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29
Q

Where should auscultation of Tricuspid area take place?

A

Left side, 4th intercostal space

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30
Q

Where should auscultation of Mitral area take place?

A

Left side, 5th intercostal space, Midclavicular Line

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31
Q

What will you hear when auscultating: Aortic area?

A

Ejection from LV

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32
Q

What will you hear when auscultating: Pulmonic area?

A

Ejection from RV- pulmonary artery

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33
Q

What will you hear when auscultating: Erb’s Point?

A

S1 and S2 as well as murmurs

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34
Q

What will you hear when auscultating: Tricuspid area?

A

Blood flow across tricuspid valve to RV

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35
Q

What will you hear when auscultating: Mitral area?

A

blood flow across mitral valve to LV filling

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36
Q

What causes a heart murmur?

A

Caused by turbulent blood flow through the heart:

  1. Increased blood viscosity
  2. structural valve defects
  3. Valve malfunction
  4. Abnormal chamber openings
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37
Q

What is an innocent murmur?

A
  • Normal, turbulent blood flow
  • Heard during systole
  • Children and young adults
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38
Q

During Peripheral vascular assessment what are you inspecting for?

A
  • skin color, temp, texture, hair distribution, lesions
  • symmetry (atrophy)
  • peripheral pulses
  • Edema
  • Superficial Thrombophlebitis
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39
Q

During Peripheral vascular assessment what are you palpating?

A
  • skin temp and capillary refill
  • Peripheral pulses
  • Edema (pitting vs. non pitting)
  • Epitrochlear lymph nodes
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40
Q

What is thrombophlebitis?

A
  • inflammation and clot due to trauma of vein
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41
Q

What aspect of the CFAm model does the genogram show?

A
  • Internal Structure
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42
Q

What aspect of the CFAM model does the ecomap show?

A
  • External Structure
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43
Q

What is an example of a difference question?

A

Did you smoke more before event X or after?

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44
Q

What is an example of a behavioural question?

A

How does your mother show that she’s afraid of your father dying?
- How did it make you feel when your wife didn’t show up?

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45
Q

What is an example of a Hypothetical/ Future oriented question?

A
  • If this conflict doesn’t change, how will it affect your family?
  • What would your health experience look like if it was perfect?
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46
Q

What is a triadic question?

A

Question about someone else…

  • How do you think your mother will cope with her cancer diagnosis?
  • If I was a fly on the wall…
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47
Q

What is circular communication?

A
  1. Behaviour -> Cognition (belief)-> Behaviour -> Affect (emotion)-> back to behaviour
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48
Q

DOHs related to smoking: people who smoke can have…

A
  • decreased education
  • decreased SES
  • decreased social support
  • increased stress
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49
Q

What is the definition of a profound nicotine addiction?

A
  • has a cigarette within 30 minutes of waking

- smokes more than 20 cigarettes per day

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50
Q

Dependence on nicotine often develops within ___ days of regular use.

A

60

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51
Q

What are the 5 A’s in the 5 A’s approach?

A
  1. Ask- what are you smoking
  2. Advise - urge every tobacco user to quit
  3. Assess- are they ready to attempt to quit
  4. Assist- use counselling/ pharmacology to help
  5. Arrange - follow up visit
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52
Q

What angle should the patient be at to find JVP?

A

45-60 degrees?

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53
Q

Where should the vertical ruler be when measuring the JVP?

A

Sternal angle/ Angle of Louis

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54
Q

Where are you measuring to with the horizontal ruler for JVP?

A

The highest point of the wave in the thoracic triangle

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55
Q

What is the normal JVP?

A

1-3 cm

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56
Q

Respiratory Assessment: Interview focuses?

A
  • cough
  • SOB
  • chest tightness or pain
  • history of respiratory illness
  • smoking
  • environmental issues (pollutants, chemicals)
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57
Q

Respiratory Assessment: Inspection:

A
  • Color
  • Symmetry
  • more…
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58
Q

Respiratory Assessment: Palpation

A
  • Assess skin
  • Assess subcutaneous tissues of chest
  • tracheal deviation
  • thoracic expansion
  • vocal/tactile fremitus
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59
Q

Where would you hear a flat sound when percussing?

A

Over bone or muscle

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60
Q

Where would you hear a dull sound when percussing?

A

over a solid organ

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61
Q

Where would you hear resonance sound when percussing?

A

normal lung, hollow structures

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62
Q

Where would you hear tympanic sound when percussing?

A

stomach, gastric air bubble

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63
Q

Where would you hear vesicular lung sounds?

A

over lung fields

64
Q

Where would you hear bronchiovesicular lung sounds?

A

right on either side of the sternum

65
Q

Where would you hear tracheal lung sounds?

A

Over the trachea (adam’s apple/ throat)

66
Q

Where would you hear bronchial lung sounds?

A

Over the bronchi (centre above clavicles under trachea)

67
Q

What are some cigarette alternatives?

A

Chewing tobacco, suns, shish, cigars/cigarellos

68
Q

Treatment options for nicotine addiction

A
  • Combo of counselling and pharmacotherapy is more effective than either alone
  • more intense the intervention, better the outcome
69
Q

What are pharmacologic options for treatment of nicotine addiction?

A
  • nicotine replacement therapy
  • non- nicotine replacement therapy
    NOTE: Clients/patients attempting to quit smoking should always be encouraged to use effective medications unless they are contraindicated in specific populations
    eg. pregnant women, smokeless tobacco users, light smokers, adolescents
70
Q

Where can we assess dermatome: C4

A

Shoulder

71
Q

Where can we assess dermatome: C6

A

thumb

72
Q

Where can we assess dermatome: C8

A

pinky

73
Q

Where can we assess dermatome: T4

A

nipple line

74
Q

Where can we assess dermatome: T10

A

umbilicus

75
Q

Where can we assess dermatome: L1

A

level of hip

76
Q

Where can we assess dermatome: L2

A

inguinal

77
Q

Where can we assess dermatome: L3

A

inside of upper leg

78
Q

Where can we assess dermatome: L4

A

medial lower leg

79
Q

Where can we assess dermatome: L5

A

lateral lower leg

80
Q

Where can we assess dermatome: S1

A

little toe

81
Q

Lobes of the brain: frontal

A

behaviour, intelligence

82
Q

Lobes of the brain: Parietal

A

intelligence, language

83
Q

Lobes of the brain: Temporal

A

behaviour, memory, speech, vision

84
Q

Lobes of the brain: Occipital

A

vision

85
Q

What is the brainstem responsible for?

A

Breathing, BP, involuntary behaviour

86
Q

If Broca’s area is impaired…

A

speech is limited, patient is aware of the inability

87
Q

If Wernicke’s area is impaired

A

fluent speech, meaningless, not aware of inability

88
Q

Mental Status exam: What does ABCT stand for?

A

A- Appearance
B- Behaviour
C- Cognition
T- Thought process

89
Q

Mental Status exam: Appearance

A

grooming, hygiene, posture , dress

90
Q

Mental Status exam: Behaviour

A
  • LOC, facial expression, speech, mood and affect
  • Emotions: feeling that tends to have clear focus; cause is self evident; shorter lived
  • Mood: more unfocused; involves a structured set of beliefs about general expectations, future pleasure,gain, loss, pain; may last for days, months, years
  • Affect: experience of the emotion; external display of the emotional experience
  • Speech & Language: quality, rate, volume, fluency
91
Q

Mental Status exam: Cognitive Function

A
  • Orientation (person, place and time)
  • Attention span
  • Recent memory (24 h diet recall)
  • Remote memory ( past jobs, health history)
  • New learning (remembering 4 unrelated words)
  • Judgment (what would you do if someone stole your car
92
Q

Mental Status exam: Thought Process and Perceptions

A
  • Thought process (makes sense, consistent and logical)
  • Thought content (what do you usually think about)
  • Perceptions (how do others treat you? Do you hear voices in your head?)
93
Q

Mental Status exam: what to consider?

A
  • Age/Stage of development (fine motor and language skills)
  • Cognitive Capacity
  • Psychosocial Development (fear/anxiety)
  • Langauge barriers
  • Cultural Influences
94
Q

What is a mini mental exam?

A
  • Standard set of 11 questions
  • 10 mins to administer
  • tests cognitive functioning ONLY
95
Q

Motor and Cerebellar System: Inspection

A
  • size and symmetry of muscles

- observe for fasciculations, tics and tremors

96
Q

Motor and Cerebellar System: Upper Body- How do we test muscle strength and cerebellum?

A
  • Muscle Strength: (wrist flexion/extension; elbow flexion/extension; arm abduction at shoulder)
  • Cerebellum (Fine motor movement: finger to nose; rapid alternating movements)
97
Q

Motor and Cerebellar System: Lower Body- How do we test muscle strength, cerebellum and gait?

A
  • Muscle strength: (hip flexion; knee extension/flexion; plantar flexion/dorsiflexion; leg abduction/adduction)
  • Cerebellum: (fine motor movement: heel to shin)
  • Gait (Normal gait- note balance and arm swing; tandem)
98
Q

What are reflexes?

A
  • defence mechanisms
  • quick response to potentially harmful stimuli
  • maintain muscle tone and balance
99
Q

What is the grading scale for reflexes?

A
  • 0= no response
  • 1+ = hypoactive
  • 2+ = normal
  • 3+ = more active
  • 4+ = hyperactive
100
Q

Should we compare reflexes bilaterally?

A

YES!!!

101
Q

Superficial Reflexes: Frontal Release- how do we test this?

A
  • Negative Babinski (toes down/flexion) = normal

- Fanning toes - suggests presence of an upper motor neuron lesion

102
Q

What are dermatomes?

A
  • Area of skin innervated by a single spinal nerve

- useful in locating exact nerve causing problems

103
Q

What is felt in the posterior column of the spinal cord?

A
  • fine touch, position and vibration
104
Q

What is felt in the lateral column of the spinal cord?

A
  • pain, crude touch and temperature
105
Q

Where to screen dermatomes for light touch and pain?

A
  • Proximal and distal extremities: (lateral aspect of upper thighs; inner aspect of upper arms; dorsal & palmer surface of hands; bottom & dorsal surface of feet
    • if unable to feel crude touch and pain, test temperature (hot/cold)
106
Q

What is stereognosis?

A

the ability to identify objects by touch without the aid of vision

107
Q

What is graphesthesia?

A

the ability to identify, using touch alone, a letter or number traced on the skin

108
Q

How do we test for pain and light touch?

A
  • client sitting with eyes closed
  • say “tell me where i’m touching you”
  • COMPARE BILATERALLy!!!
109
Q

How do we test for fine touch? 2 Ways

A 
Stereognosis 
- close eyes
- place object in hand
- test bilaterally with different objects
- note speed and accuracy
- astereognosis (inability to identify object)
Graphesthesia
- close eyes
- draw letter or number on hand
- test bilaterally
- not speed and accuracy
- agrahesthesia (inability to identify figure)
110
Q

How do we test vibratory sensation?

A
  • close eyes
  • strike tuning fork and place on distal bony prominence
  • say “tell me when you feel the vibration start and stop”
111
Q

What is point localization?

A
  • touch patient’s skin

- open eyes and point to where touched

112
Q

What is extinction?

A
  • simultaneously stimulate the same area on both sides of the body
  • ask how many points felt and where
113
Q

Cranial Nerves- Name number and function: Olfactory

A
  • I

- smell

114
Q

Cranial Nerves- Name number and function: Oculomotor

A
  • III

- eyelid and eyeball movement

115
Q

Cranial Nerves- Name number and function: Trigeminal

A
  • V

- chewing, face & mouth, touch & pain

116
Q

Cranial Nerves- Name number and function: Abducens

A
  • VI

- turns eye laterally

117
Q

Cranial Nerves- Name number and function: Glossopharyngeal

A
  • IX

- taste, senses carotid BP

118
Q

Cranial Nerves- Name number and function: Vagus

A
  • X

- senses aortic BP, slows HR, stimulates digestive organs, taste

119
Q

Cranial Nerves- Name number and function: Hypoglossal

A
  • XII

- controls tongue movement

120
Q

Cranial Nerves- Name number and function: Optic

A
  • II

- vision

121
Q

Cranial Nerves- Name number and function: Trochlear

A
  • IV

- turns eye downward and laterally

122
Q

Cranial Nerves- Name number and function: Facial

A
  • VII

- controls most facial expressions, secretions of tears & saliva and taste

123
Q

Cranial Nerves- Name number and function: Vestibulocochlear

A
  • VIII

- hearing, equilibrium

124
Q

Cranial Nerves- Name number and function: Spinal Accessory

A
  • XI

- controls tongue movements

125
Q

What is the location in the breast that has the highest incidence of a breast tumor occurring?

A

upper outer aspect extending to the axillary tail of spence

126
Q

T/F all women should complete a yearly breast exam?

A

False- monthly

127
Q

What are the 4 steps in a breast self examination?

A
  1. observe breasts in mirror with arms at sides, overhead, pressed against hips and pressed together at waist, leaning forward
  2. palpate breasts while sitting or standing with one hand behind head- use concentric circles to ensure all tissue is palpated
  3. Repeat while lying down
  4. Palpate areolae and nipples- compress nipple and check for discharge
128
Q

What changes would you be noticing during the breast exam?

A
  • new lump in armpit area, unusual bruising, redness, warmth or rash to the breast area, nipple changes (crusting, turning inward or discharge) and dimpling or puckering of the skin
129
Q

T/F Men should begin testicular self exams at age 21

A

F- should be done regularly from puberty (age 15)

130
Q

5 questions you might ask to assess personal health history factors during a testicular exam

A
  1. COLDSPAA pain, discharge, swelling
  2. Erectile dysfunction
  3. health history (i.e. mumps)
  4. Behaviours (contraception, testicular self exam, alcohol, recreational drug use)
  5. Occupational exposure (may cause decreased sperm count and PPE reduces testicular damage
131
Q

3 reasons a man may not get a testicular exam

A

Machismo, inexpressiveness, denial/fear

132
Q

what would a nurse be assessing during a scrotal inspection/ palpation?

A

Scrotum should be pear-shaped with left side hanging lower than right.

  1. Skin should be wrinkled with no swelling, redness, distended veins and lesions – note bilaterally
  2. Transilluminate the mass, if noted (testicle is nontransparent)
  3. Inspect inguinal area – should be flat
  4. Scrotal sacs should be nontender, soft and boggy with structures moving easily within
  5. Rotate testes with warm hands – each testes is non tender, oval-shaped, walnut-sized, smooth, elastic and solid
133
Q

What are the risk factors for breast cancer?

A
  • age greater than 49
  • close relative diagnosed before menopause
  • family history of ovarian cancer
  • personal history of breast/ovarian cancer
  • benign breast conditions
  • radiation treatment
  • bottle feeding
  • first pregnancy greater than 30 years of age
  • lack of anti oxidants in diet
  • sedentary lifestyle
  • alcohol
  • smoking/ exposure to second hand smoke
  • obesity
  • estrogen replacement therapy
  • oral contraceptive use
134
Q

what are 2 secondary prevention strategies for breast cancer

A
  • mammography
  • BSE
  • screening for BRCA 1 and BRCA 2 genes
  • elective surgery for the genes
135
Q

What is a strategy a public health nurse might use to change culturally based, idiosyncratic beliefs a community holds about breast cancer

A
  • health teaching by breast cancer patients of same race/ ethnicity
  • healthy teaching in settings such as churches and community centers
136
Q

How to best prevent testicular cancer?

A

there is no real way to prevent most cause of the disease since all risk factors exist from birth

137
Q

T/F: Hormonal influences have no effect on a women’s breasts therefore she can complete her breast exam at any time of the month.

A

F- breasts are affected by estrogen and progesterone levels so it is best to do breast exam right after menstruation or on days 4-7 of a regular menstrual cycle

138
Q

T/F: men cannot get breast cancer

A

F- 1% of men get breast cancer

139
Q

T/F: breastfeeding does not reduce the risk of breast cancer

A

F- breast feeding for 1-2 years is recommended

140
Q

T/F: women aged 60 and older should have their first screening mammogram.

A

False- average risk is at age 40 (by 30 but not before 25)

141
Q

What are signs you would teach a woman to look for that indicate the need for assessment by a physician or nurse practitioner (besides a lump)

A
  • nipple discharge and dimpling
142
Q

Influences that may discourage a woman from being comfortable talking about her breasts and breast health.

A

cultural factors, knowledge/attitudes/beliefs, shyness, embarrassment, fears, myths, size of breasts

143
Q

5 signs/symptoms of testicular cancer that you would discuss with male clients

A
  1. lump or enlargement in either testicle
  2. feeling of heaviness in the scrotum
  3. dull ache in the abdomen or groin
  4. sudden collection of fluid in the scrotum
  5. pain or discomfort in a testicle or scrotum
  6. enlargement or tenderness of the breasts
144
Q

What race has the highest risk for testicular cancer?

A
  • Caucasian
145
Q

explanation of testicular cancer in client entered language to a teenager

A

-collaborative partnerships
-understanding of growth and development
- understanding of risks
-

146
Q

How would you communicate how to complete a testicular exam to someone who is ESL?

A
  • Use gestures and pictures

- Is he able to demonstrate

147
Q

T/F: testicular cancer has high cure rate if detected early

A

True: increasing incidence but decreased mortality due to better screening measures

148
Q

T/F: testicular cancer has high cure rate if detected early

A

True: increasing incidence but decreased mortality due to better screening measures

149
Q

How do you assess cranial nerve I?

A

Olfactory nerve

- with eyes closed, have client identify a familiar scent under nose

150
Q

How do you assess cranial nerve II?

A

Optic nerve

  • acuity: read from Snellen Chart and newspaper
  • Visual fields: client focuses on your nose and covers one eye. Test ability to see finger in 4 visual quadrants
151
Q

How do you assess cranial nerve III, IV, VI?

A

Oculomotor, Trochlear, Abducens

  • eyelid covers 2mm of eyelid
  • assess 6 cardinal fields (downward and lateral is CN IV), normal smooth and coordinated
  • check pupillary response (direct and indirect response)
  • Check accommodation (pupils constrict, eyes converge)
  • check for diplopia that resolves when one eye is closed (IV nerve palsy)
152
Q

How do you assess cranial nerve V?

A

Trigeminal nerve:
- clench teeth, palpate temporal and master muscles then try to pull down on client’s chin
- test sharp dull side to side
- test light touch side to side
client looks away, touch cornea with cotton wisp

153
Q

How do you assess cranial nerve VII?

A

Facial nerve:

  • smile, frown, wrinkle forehead, show teeth, puff cheeks, raise eyebrows
  • close eyes against resistance
  • purses lips
154
Q

How do you assess cranial nerve VIII?

A

Acoustic:

  • Weber: tuning fork on centre of forehead
  • Rinne: tuning fork on mastoid process then, test hearing when vibration fades
155
Q

How do you assess cranial nerve IX and X?

A

Glossopharyngeal and Vagus:

  • touch pharynx with tongue depressor
  • have client sip water
  • say AHH- note bilateral, symmetrical rise of uvula and soft palate
156
Q

How do you assess cranial nerve XI?

A

Spinal Accessory Nerve:

  • shrug shoulders against resistance
  • turn head against resistance
157
Q

How do you assess cranial nerve XII?

A

Hypoglossal:

  • have patient stick out tongue
  • move tongue side to side

Nursing 1213 (2 decks)

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