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Assessment Final > Test 1 and Test 2 Review > Flashcards

Test 1 and Test 2 Review Flashcards

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1
Q

Referred Pain

A

pain can originate in part of the body but be perceived in a distant organ

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2
Q

Gate Theory of pain

A

recognizers the relationship between pain and emotions

ex. stub toe- won’t grab toe you will grab foot

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3
Q

Phantom pain

A

may occur in someone who has lost a limb - may feel burning, crushing, cramping or twisted

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4
Q

Psychogenic pain

A

physical pain that cannot be identified

Ex. Sex abuse

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5
Q

Intractable pain

A

persistant pain that is resistant to therapy

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6
Q

Nociceptive pain

A

only respond to tissue damage or other intense chemical, mechanical, or thermal stimulation:

3 types
Somatic - deep pain ligaments, bones, tendons
Cutaneous - skin/subcutaneous
Visceral - organ pain

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7
Q

What does NIPS assess?

A

Neonatal
Infant
Pain
Scale

Newborn babies - rates babies on a scale of 0-1 with regard to breathing pattern, arms and leg movement, state of arousal, and crying (0-2) Higher the score can indicate problems

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8
Q

Mechanisms of pain

A

Transduction
Transmission
Perception
Modulation of Pain

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9
Q

What are things to remember when lifting?

A

Avoid twisting the thoracic spite and avoid flexion of the back; want to use the longest and strongest muscles (legs and arms) Tighten your abdominals and keep the object your going to life close to you/in your center of gravity

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10
Q

What are the 4 Ps to prevent fall

A

Every 2 hours assess:

Pain, Potty, Positiong, (IV) Pump Safety

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11
Q

Where is S2 best heard

A

at the base of the heart
**remember the base is at the top of the heart
SL closure
beginning of diastole

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12
Q

Where is S1 best heard?

A

at the Apex of the heart
** apex is at the 5th ICS below the base
AV closure
beginning of systole

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13
Q

Dextrocardia

A

when the heart is on the right side of the body and not the left

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14
Q

Bruits

A

abnormal sounds that can indicate a murmur or build up of plaque in the carotid artery (should normally sound like the ocean)

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15
Q

During percussion flatness is heard over

A

muscle/bone

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16
Q

During percussion tympanic is heard over

A

abdominals

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17
Q

During percussion resonance is heard over

A

lungs

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18
Q

During percussion dullness is heard over

A

a full bladder, lungs that might have fluid or mass in them

normal in spleen and liver

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19
Q

All People Eat Turkey Meat

A 
Apical
Pulmonic (2nd ICS)
Erbs Point (3rd ICS)
Tricuspid 4th/5th ICS (4th in kids)
Mitral/Apex (5th ICS)
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20
Q

How long would you want to listen to an apical pulse for

A

60 seconds

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21
Q

xanthelasma

A

fat deposits above eye lids (cardiac assessment)

**means they have an elevated lipid level

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22
Q

arcus senilis

A

whitish round color around the eye (typically normal in older adults)

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23
Q

What are the normal respiratory rates

A

12-20 breaths

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24
Q

What are the 6 vital signs

A

Temp, Pulse, BP, Respiration, O2 Sat

Paaaaiiiiinnnnn

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25
What are the sources of heat loss
Skin Evaporation of Sweat Warming and Humidfying inspired air Eliminating Urine and Feces
26
When is your core temp the highest/lowest
highest between 4-7pm and lowest in the morning
27
What and where is your best core temperature
Esophageal
28
Contraindications of using a rectal thermometer
``` hemmorhoids diarrhea newborns rectal bleeding/surgery steriods cardiac ```
29
Normal pulse rates
newborns/babies 120-160bpm | adults 60-100bpm
30
What are 2 places to assess rate in peripheral pulses
radial and apical
31
pulse deficit
difference between apical and radial pulses
32
Kussamal breathing
shallow, rapid breathing often associated with metabolic acidosis
33
Contraindications for taking BP?
``` tremors breast removal vasectomy av shunt IV in that arm stroke ```
34
ausculatory gap
temporary disappearance of korotkoff sounds - typically between 1st and 2nd sounds ** Document and and let the provider know
35
Dx of Hypertension
3 readings greater than 140/90
36
orthostatic hypertension
postural hypertension - increase in BP when a person stands up --- this increases peoples risk for falls
37
PQRST
``` PRECIPITATION FACTORS QUALITY/QUANTITY REGION/RADIATION/RELATED SYMPTOMS SEVERITY TIMING ```
38
What is the review of systems
2 types -focused or complete health history Includes systematic head to toe assessment Use open ended questions
39
Psychosocial assessment would include
``` preferences for food (vegan/kosher) activity and exercise recreation - pets, hobbies, stress relief practices personal habits fears/concerns religion sexuality patterns occupational/socioeconomic status ```
40
What are the steps in the Nursing process
``` Assessment (Nursing) Dx Planning Implementation Evaluation Revision of care ``` ***ADPIE
41
Pitfalls to data recording
``` omitting date interpretation of data assuming/hastely interpreting data (think someone automatically smokes since they smell like it) Failure to follow up Poor communication ```
42
Respiratory Landmarks anterior and posterior
ICS 2,4,6,6 | T 1,4,7,10, (9 and 5 laterally)
43
Lungs bifurcate at
ICS 2 | T 4
44
Bronchial sounds
heard above bifurcation and expiratory> inspiratory
45
Bronchialvesicular
heard at the bifurcation E=I
46
Vesicular
heard below the bifurcation I>E
47
hyper-resonant
very loud/very low - may indicate abnormal air trapping in the lungs (overinflated
48
croup
seal like arching cough which is indicative of a narrowing of the passageway through the larynx - often in children; tx - breathing in cold air to decrease swelling (children 3months - 6 years)
49
Rhonchi
rattling sound caused by excessive mucus | heard in the upper part of the lungs because they occur in the bronchi!
50
Crackles
fine and course - means filled with fluid and typically heard in the lower portion of the lungs
51
Shunting
imbalance in V/Q ratio = diversion (Ventilation fails | **if one part of the lung isn't working properly it is going to tax the other part of the lungs for gas exchange
52
pneumothorax
collapsed lung
53
stridor
high pitched breath sound - typically associated with people who have croup
54
Clubbing of nails could be indicative of
COPD or chronic smokers
55
Meconium
first stool
56
what is the proper order of assessment for the abdomen
Inspection Auscultatioin Percussion Palpation
57
What are the 4 types of abdominal distensions
flat scaphoid (caved in) (thin patients) rounded (infants and toddlers) protuberant - pregnant women/otherwise an indication that something may be wrong
58
Where is kidney and renal tenderness assessed
costovertebral angle
59
oliguria
low output of urine
60
anuria
no output of urine
61
torticollis
lateral deviation of the neck
62
cheiliosis
painful inflammation and cracking of the corners of the mouth
63
Cognitive development during the 1st year of life is also called the ___________phase and includes what 3 major tasks
sensorimotor separation (realize that self is separate from other objects) object permanence mental representation (recognizing symbols)
64
Apgar Scale
``` HR Respirations Muscle tone Reflex Irritability Color ``` **rated on a scale of 0-2 - assessed 1 and 5 minutes after birth score of 8-10 is excellent 4-7 is guarded + 0-2 is critical
65
What is the normal head circumference
33-35cm microcephaly - congenital malformation/infectioin macrocephaly - hydrocephalis (90% of normal body) measurement of the crow to the rump should be about equal to the head circumference
66
When do tears begin in a newborn
after 2 months
67
Epstein's pearls
small white pearl-like epithelia cysts on the palate are normal for newborns and disappear within a few weeks
68
At what age would expect the anterior fontanels to close
between 12-18 months
69
At what age would you expect the posterior fontanelles to close
3 months
70
Magnet reflex
flexing the newborns legs and applying pressure to the soles of the feet - normal response should be extension of legs
71
What type of breath sounds is normally heard in newborns
Bronchial
72
Which vision change is frequently seen in adolescents?
myopia (nearsightedness)
73
HEENT assessment of an adolescent what maybe be palpable owing to hormonal changes associated with puberty?
Thyroid
74
According to Erikson what is the developmental task for the school-age children 6-12? and 12-18?
Industry vs Inferiority Identity vs. Role Diffusion
75
Percocious menarche
less than 8 years old | **normal age between 10 and 12; ovulating more = increased risk
76
BRCA test
+ BRCA1 = 80% chance of BC | + BRCA2 = 45% chance of BC

Assessment Final (7 decks)

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