Test 3 Flashcards
1
Q
Which pain scale is a scale of 0-10 (0: no pain; 10: worst)?
A
Numeric pain scale
2
Q
Which pain scale simply asks the patient, “would you describe your pain as mild, moderate, or severe?”
A
Simple descriptor pain scale
3
Q
Which pain scale is white on the left side and gradually turns darker red (the more red, the worse the pain)?
A
Visual Analog Scale
4
Q
Which pain scale uses faces at varying levels of distressed that is geared towards children?
A
Wong-Baker faces pain rating scale
5
Q
Which pain scale uses pictures of faces at different levels of distress that is geared towards non-pediatric patients?
A
Revised face pain scale
6
Q
Which pain scale is used on patient with advanced dementia who have trouble communicating?
A
PAIN-AD scale (Pain Assessment in Advanced Dementia)
7
Q
Which pain scale is used in pediatric patients that is a scoring pattern of 0-2 for each behavior?
A
FLACC Pain Scale
8
Q
Hypnosis, distraction, guided imagery, music therapy, and humor are all kinds of what type of pain intervention?
A
Non-pharmacological/Relaxation therapies
9
Q
What type of pain does not respond well to opioid medications?
A
Neuropathic pain
10
Q
What are the three kinds of pain?
A
- Nociceptive
- Neuropathic
- Cancer
11
Q
The pain that is caused by tissue damage as a result of trauma, surgery, or inflammation.
A
Nociceptive
12
Q
Pain that arises from a nerve injury or damage to the neurological pathway transmitting pain signals.
A
Neuropathic
13
Q
What 2 ways do cancer patients experience pain?
A
Nociceptive and neuropathic
14
Q
What type of pain comes from injuries that are in the skin or subcutaneous tissue? (Ie: paper cut or burn)
A
Superficial pain (pain is sharp or severe)
15
Q
What time of pain arises from the musculoskeletal system? (Involves ligaments, tendons, nerve and blood vessels, or bones)
A
Somatic pain
16
Q
What type of pain comes from deep internal pain receptions is a signal of organ pain?
A
Visceral pain
17
Q
What type of pain is felt in a body part or area that has been amputated?
A
Phantom pain
18
Q
What type of pain may present as referred pain?
A
Visceral pain
19
Q
What type of pain has a rapid onset and short duration?
A
Acute pain
20
Q
What type of pain lasts longer than 6 months?
A
Chronic pain
21
Q
What type of pain is persistent and highly resistant to any kind of pain relief?
A
Intractable pain
22
Q
What 5 factors influence pain?
A
- Emotions
- Past experiences
- Sociocultural influences
- Communication ability
- Cognitive impairments
23
Q
What is the purpose of a comfort function goal?
A
To come up with a realistic plan for what an acceptable level of pain will be (helps determine patient ECO)
24
Q
Name 5 nonverbal signs of pain?
A
- Increased HR
- Elevated pulse
- Increased RR
- Behavioral changes
- Grimacing/Guarding
25
The combination of several types of pain management
Multimodal pain management
26
When a medication is not as effective without an increase in dose, the patient has ______ to the drug.
Tolerance
27
When the patient will experience withdrawal if the medication is not given.
Dependence
28
Aberrant drug-related behaviors that make patients with chronic pain look like addicts (the behaviors stop if the opioid is increased and pain improves)
Pseudo addiction
29
Compulsive, psychological need for a medication.
Addictions
30
The combination of physical and mental effects after a person stops using a medication.
Withdrawal
31
What is the opioid reversal agent called?
Naloxone (Narcan)
32
What is the most important thing to check for when administrating an opioid?
Patient’s respiratory rate
33
What are some safety measures of PCA?
- Must be controlled only by patient
- 2 nurses to set up
- double check medication pump consistently
- educate the family
34
What type of exercise involves muscle contraction without motion?
Isometric
35
What type of exercise involves movement of the joint during muscle contraction?
Isotonic
36
What type of exercise is performed with a variable resistance to movement during the range of motion (sitting in chair lifting soup cans)?
Isokinetic
37
What type of exercise occurs when the amount of oxygen taken in by the body meets or exceeds the amount of oxygen required to perform the activity (jogging, brisk walking)?
Aerobic
38
What type of exercise occurs when the amount of oxygen in the body does not meet the amount of oxygen required; therefore the muscles must obtain energy from the metabolic pathways? (Heavy weight lifting)
Anaerobic exercise
39
What is intentional movement?
Mobility
40
What is movement of the body the increases energy expenditure?
Physical activity
41
What are the proper body mechanics for a nurse? (6)
1. Proper spinal alignment (knees hip-width apart)
2. Lift with knees, not back
3. Avoid bending or twisting
4. Use assistive aids as needed
5. Raise the bed
6. Push or pull instead of lift
42
A state in which the patient has insufficient physical stamina or psychological energy to carry out their daily activities?
Activity intolerance
43
Something preventing the patient from beginning or completing the physical activity
Impaired mobility
44
The type of ROM exercise a patient can perform by him or herself.
Active Range of Motion (AROM)
45
The type of ROM that the nurse, PT, or family member (somebody other than the patient) is performing by manipulating the joint.
Passive Range of Motion (PROM)
46
Pain is what type of experience?
Subjective
47
What is the most serious side effect of opioid medication?
Respiratory depression
48
What are 5 negative effect of immobility?
1. Constipation
2. Osteoporosis
3. Decreased glucose tolerance
4. Atelectasis
5. Deep Vein Thrombosis (DVT)
49
Name 4 interventions for impaired physical mobility.
1. Use assistive devices
2. Promote independence
3. ROM exercises
4. Maintain safety
50
The quality of bending something without breaking
Flexibility
51
The force against against something making it harder to perform
Resistance
52
The condition of being physically fit and healthy
Fitness
53
When the urine output is less than 400 mL in 24 hours.
Oliguria
54
When the urine output is excessive or frequent.
Polyuria
55
When there is prevents of blood in the urine that can be microscopic or gross (seen with the naked eye).
Hematuria
56
Painful urination
Dysuria
57
The presence of protein in the urine
Proteinuria
58
When something is toxic or causes damage to the kidney(s).
Nephrotoxic
59
When damage actually occurs in the kidney.
Nephropathy
60
How can urinary retention be evaluated?
Bladder scan
61
What is the normal level of specific gravity in urine?
1.002-1.030
62
What is the normal value of proteins, glucose and ketones in the urine?
Negative
63
What type of incontinence occurs when there is an increased intra-abdominal pressure causing loss of urine?
Stress
64
What type of incontinence occurs when occurs when the urgency to urinate is so sudden that there is an involuntary loss of urine?
Urge
65
What type of incontinence occurs when the bladder is very full and the urine leaks out as the bladder keeps filling?
Overflow
66
What type of incontinence occurs when the patient cannot make it to the bathroom in time (usually temporary)?
Functional
67
What is measuring the amount of waste product left in the blood stream?
BUN
68
What is the byproduct of muscle breakdown?
Creatinine
69
What is the normal creatinine levels?
0.5-1.2 mg/dL
70
What is the normal BUN levels in urine?
8-21 mg/dL
71
What can abnormal renal labs signify? (Name 6)
- renal failure
- impaired rental perfusion
- renal inflammation
- kidney obstruction
- dehydration
- excessive protein intake
72
What does the presence of nitrates, leukocyte esterase, RBCs, WBCs, and bacteria all indicate?
Infection
73
What would a urine sample of someone with a UTI contain (any combo of these)?
- cloudy or with sediment
- nitrates
- leukocyte esterase
- hematuria
- WBCs
- bacteria
74
When should an interdwelling catheter be removed?
When it is no longer needed
75
Name 6 interventions to promote urinary excretion.
1. Bladder training
2. Ask pt about normal routine
3. Provide privacy
4. Good perineal hygiene
5. Proper positioning
6. Pour warm water over perineum
76
7 interventions for an indwelling catheter.
1. Use sterile procedure
2. Keep bag below waist level
3. Never let bag get full
4. Keep tube free of kinks
5. Use standard precautions
6. Leave seal intact
7. Regular perineal care
77
How long does a catheter need clamped off in order to obtain a urine sample?
At least 30 min
78
What type of technique is used when the patient cleans meatus and urine is collected midstream?
Clean catch technique
79
What is the decrease in bowel movements from a patient’s normal routine called?
Constipation
80
How often should a person have a bowel movement?
Whatever is the patient’s normal as long as their is no straining, urgency or bleeding occurring
81
What are some interventions for constipation?
- stool softeners
- add a laxative if stool softeners are ineffective
- enema
- digital disimpaction
82
What is the primary intervention for diarrhea?
Supportive care
83
What type of diet should a person with diarrhea have?
BRAT diet (bland, no spicy, clear liquids, no dairy)
84
What classifies chronic diarrhea?
Longer than 1 month
85
Formed with the stoma is in the small intestine
Ileostomy
86
Where the bowel diversion is made within part of the large intestine or the colon
Colostomy
87
How should a stoma appear?
Pink or dark red
88
If a stoma appears dusky, gray, purple, or very pale what could this indicate?
Tissue ischemia
89
What type of foods should a person with an ostomy bag avoid?
Gas producing (cauliflower, Brussel sprouts, garlic, onions, beans, peas, and dairy)
90
What are two risk factors for patients received IV contrast for an abdominal CT scan?
1. Allergy to dye
| 2. Renal dysfunction
91
What is the mild alteration in peristalsis not resulting in diarrhea or constipation?
GI motility
92
What is the normal presence of GI gas called?
Flatus
93
What is the excessive GI gas that can lead to pain and bloating called?
Flatulence
94
Chronic constipation is classified by constipation lasting how long?
3 months
95
The biggest transitional phase for middle-aged women is ________.
Menopause
96
Which gender tends to have a longer life span?
Women
97
What age group is considered older adults?
65 years and older
98
Who are the youngest old?
65-74
99
Who is the middle old?
75-84
100
Who is the oldest old?
85 and up
101
Who is the fasting growing age group?
The oldest old (85 and up)
102
What age group does the Intimacy Vs Isolation affect?
Young and Middle Adulthood (19-40 yr old)
103
What Erickson stage is geared towards those in middle adulthood (40-65)?
Generativity vs Stagnation
104
What is the Ego vs Integrity stage?
Older population reflects on their life (happy vs regrets)
105
Interventions for older adults
- maintain physical activity
- fall prevention
- promote independence
- allow extra time
106
Occurs when a patient is taking multiple medications and the risk of the medications interacting is high.
Polypharmacy
107
How well a patient can complete their daily activities with vigor while remaining alert and without fatigue and preserving some energy to pursue other more leisurely activities
Fitness
108
What is the most common bed position?
Fowler’s (60 degree elevation)
109
What position is good for relieving pressure from the sacrum?
Lateral position (side laying)
110
What positions are good for patients with respiratory issues?
Fowler’s and High Fowler’s
111
What position is good for patients receiving an enema?
Sim’s
112
What turning technique is used when the patient’s spine must be in a straight alignment?
Logrolling
113
What position is good for relieving gas or flatulence?
Sim’s
114
What position is good for relieving back pain?
Lateral position
115
What position puts extra pressure on the chest?
Prone
116
What position puts extra pressure on the sacrum?
High-Fowler’s position
117
Shopping, cooking, and managing money are all examples of what?
Independent activities of daily living
118
What three cancers are associated with the middle-aged population?
Breast
Prostate
Colon
119
What type of nutritional intervention does a menopausal women possibly need?
Increase of calcium and vitamin D
120
What are common problems with middle-aged adults?
- cancer
- heart disease
- obesity
- domestic abuse
- violence
121
What type of assessments do middle-aged individuals need?
- lipid panel
- blood glucose
- pelvic exam
- mammograms
- rectal exam
- colonoscopies
- eye exams
- osteoporosis screenings
122
What theory proposes that repressed insults and accumulation of waste over time eventually causes the cells to wear out?
Wear and Tear Theory
123
What aging theory hypothesizes that cell have a pre-programmed and finite cell division number from birth
Genetics theory
124
What cell theory hypothesizes that a malfunction in the cell causes cellular changes in the cell’s DNA?
Cellular malfunction theory
125
What cell theory hypothesizes that cells change with age so much that the body doesn’t recognize the self-cells any longer.
Autoimmune Theory
126
What is the peaceful state of non anxiety and easy activity called?
Rest
127
What is a decreased level of consciousness that allows the brain to restore its function?
Sleep
128
What can lack of sleep lead to?
Overeating
Glucose intolerance
Insulin resistance
129
How many stages of sleep is there?
4 (3 stages are non-REM)
130
How do carbs affect sleep?
Can cause blood sugar changes causing a person to wake up
131
How long before bed should a pt stop exercising?
2 hours
132
What is the patterns of waking behaviors appearing during sleep called?
Parasomnias
133
Give 4 examples of parasomnias
1. Sleepwalking
2. Nocturnal enuresis (bed wetting)
3. Night terrors
4. REM disordered behavior
134
What kind of diagnosis is insomnia?
Medical and nursing
135
What is insomnia?
Characterized by difficulty falling asleep, staying asleep, or inability to fall back asleep once prematurely awakened
136
What are dyssomnias?
- insomnia
- sleep apnea
- hypersomnia (excessive sleeping/sleepiness)
- circadian disorders
- restless leg syndrome
- narcolepsy
137
What type of sleep must be made up if not enough time is spent in it?
REM sleep
138
What is the most severe type of sleep disturbance?
Sleep apnea
139
How do you correct an error in a patient’s chart?
One line and initial (NEVER use white out or scribble it out)
140
Why are incidence reports made?
To promote safety and quality assurance
141
Where in a patient’s medical record will you find information about the patient’s allergies?
1. Medication administration record
| 2. Kardex
142
What are the six rights of medication administration?
1. Time
2. Dose
3. Route
4. Patient
5. Medication
6. Documentation
143
What are the 3 checks for the RIGHT medication?
1. When removed from storage
2. When preparing
3. When administering
144
What three ways can an order be communicated?
1. Written
2. Verbal
3. Telephone
145
What should be included on a medication order?
Medication, dosage, route, when and how many times it should be taken a day
146
What is a SOAPIE?
Organized assessment data on a nursing care plan?
147
What does SOAPIE stand for?
```
S- Subjective data
O- Objective data
A- Assessment/Analysis
P- Plan for documentation (long/short term)
I- Intervention
E- Evaluation
```
148
List 4 advantages of EHRs
1. Eliminates need for paper
2. Built in protocols
3. Medical errors are reduced
4. Accessibility by multiple providers
149
List 4 disadvantages of EHRs
1. Expense
2. Required downtime
3. Learning curve
4. Lack of integration
150
How should a telephone order be written down?
- similar to verbal orders
- transcribed into pt’s record
- provider required to co-sign WITHIN 24 hours
- re-clarify questions
