week 4 ati-- ch 26 & hw

Question 1

dyspnea

Answer 1

shortness of breath

Question 2

Kassmaul Respirations

Answer 2

abnormally deep & rapid breaths w/ REGULAR ryhthym

**metabolic/diabetic acidosis & kidney disease

Question 3

Cheyene Strokes

Answer 3

IRREGULAR shallow to deep breaths followed w hyperventilation then apnea

*stroke, increased ICP, tumor or heart failure

Question 4

valsalva maneuver

Answer 4

lowers blood pressure & stimulates vagus nerve

*client bears down as if bowel movement

Question 5

tachycardia
vs
bradycardia

Answer 5

tachy: pulse >100
brady: pulse <60

Question 6

apical pulse

Answer 6

heart rate heard @ base of heart
**4th intercostal space (child
**5th intercostal space (adult)

Question 7

pulse defecit

Answer 7

difference between apical pulse & peripheral pulse

Question 8

Pulse ratings

Answer 8

0 = absent
+1 = weak
+2 = normal
+3 = strong
+4 =bounding

Question 9

Body temp

Answer 9

normal= 96.8 -100.4
fever= 100.4+

Question 10

Respiratory Rates

Answer 10

*newborn (birth-28 days) = 30-60

*1mo - 3yrs = 25-30

*3-12 yrs = 20-25

*12-20yrs = 16-20

*20+ = 12-20

Question 11

eupnea

Answer 11

normal breathing

Question 12

newborn pulse

Answer 12

110-160bpm
*birth- 28 days

Question 13

infant pulse

Answer 13

90-160 bpm
*1mo-1yr

Question 14

toddler pulse

Answer 14

80-140
*1-3yrs

Question 15

preschool pulse

Answer 15

70-120
*3-6yrs

Question 16

school age pulse

Answer 16

60-110
*6-12yrs

Question 17

adolescent pulse

Answer 17

50-100
*12-20yrs

Question 18

adult pulse

Answer 18

60-100
*20+yrs

Question 19

normal blood pressure for toddler

Answer 19

systolic: 85-91
diastolic: 37-49
*females slightly higher

Question 20

normal blood pressure for preschooler

Answer 20

systolic= 89-98
diastolic = 46-54
*females higher

Question 21

normal blood pressure for school age

Answer 21

systolic: 94-106
diastolic: 55 - 62

Question 22

toddler hypertension

Answer 22

systolic: 103+
diastolic: 56+

Question 23

preschool hypertension

Answer 23

systolic: 107+
diastolic: 65+

Question 24

school age hypertension

Answer 24

systolic: 111+
diastolic: 74 +

Question 25

to diagnose pediatric hypertension

Answer 25

healthy BMI & blood pressure at or above 95th percentile for age on 3 separate visits

Question 26

newborn blood pressure

Answer 26

64/41

Question 27

Hypertension stages

Answer 27

**Elevated systolic: 120-129 diastolic: <80 **Stage 1 systolic:130-139 diastolic: 80-89 **Stage 2 systolic: 140+ diastolic: 90+ **hypertensive crisis systolic: 180+ diastolic: 120+

Question 28

cardiac output

Answer 28

amount of blood pumped into system within 1 minute CO= SV x HR

Question 29

stroke volume

Answer 29

amount of blood ejected by the ventricle during one contraction

Question 30

pain threshold vs pain tolerance

Answer 30

THRESHOLD: point at which a stimulus causes the client to perceive pain TOLERANCE: how much of a stimulus the client is willing to accept

Question 31

nociceptive pain

Answer 31

referred pain *throbbing, aching

Question 32

neuropathic pain

Answer 32

nerve pain *numbness, burning, intense, shooting, & itching

Question 33

negligence vs malpractice

Answer 33

negligence--failure to act malpractice---act itself

Question 34

opioid scale

Answer 34

S.B.I.R.T S--screening B--brief I--intervention R--referral to T--treatment

Question 35

nemonic to assess pain

Answer 35

P.Q.R.S.T. P--precipitating cause Q-- quality R-- region S--severity T--timing

Question 36

pain scales for children

Answer 36

*Wong Baker FACES scale (age 3+) *FLACCS Scale (observational 1-5 min awake, 5min+ sleeping)

Question 37

pain scale for neonates

Answer 37

CRIES Scale (0-2pts each category w/ 10pts total)

Question 38

a nurse provides an introduction to a client as the first step of a comprehensive physical exam. Which of the following strategies should the nurse use with this client? (sap) 1. Address the client w/ the appropriate title & their last name 2.Use a mix of open- & closed- ended questions 3. Reduce environmental noise 4. Have the client complete a printed history form 5. Perform the general survey before the exam

Answer 38

2.Use a mix of open- & closed- ended questions 3. Reduce environmental noise 5. Perform the general survey before the exam

Question 38

A nurse in a provider's office is documenting findings following an exam performed for a client new to the practice. Which of the following parameters should the nurse include as part of the general survey? (sap) 1. Posture 2. Skin lesions 3. Speech 4. Allergies 5. Immunizations

Answer 38

1. Posture 2. Skin lesions 3. Speech

Question 39

a nurse is collecting data for a comprehensive physical exam. After inspecting the client's abdomen, which of the following skills of the physical exam process, should the nurse perform next? 1. Olfaction 2. Auscultation 3. Palpation 4. Percussion

Answer 39

2. Auscultation

Question 40

a nurse is preparing to perform a comprehensive physical exam of an older adult client. Which of the following interventions should the nurse use in consideration of the client's age? (sap) 1. Expect the session to be shorter than for a younger client 2. Plan to allow plenty of time for position changes 3.Make sure the client has any essential sensory aids in place 4. Tell the client to take their time answering questions 5. Invite the client to use the bathroom before beginning the examination

Answer 40

2. Plan to allow plenty of time for position changes 3.Make sure the client has any essential sensory aids in place 4. Tell the client to take their time answering questions 5. Invite the client to use the bathroom before beginning the examination

Question 41

A nurse in a provider's office is performing a physical exam of an adult client. Which part of the hands should the nurse use during palpation for optimal assessment? 1.Palmar Surface 2. Fingertips 3.Dorsal Surface 4. Base of the fingers

Answer 41

Dorsal Surface

Question 42

general survey includes

Answer 42

1. physical appearance 2. body structure 3.mobility 4. behavior 5. vital signs

Question 43

Abdomen Exam Sequence

Answer 43

1.inspect 2.auscultate 3. percuss 4. palpate **avoids altering bowel sonds

Question 44

Exam Sequence

Answer 44

1. Inspect 2. Palpate 3. Percuss 4.Auscultate

Question 45

dorsal part of the hand feels

Answer 45

temperature

Question 46

palm of hand feels

Answer 46

vibration

Question 47

direct percussion vs indirect percussion

Answer 47

direct = touch indirect = hand flat of surface

Question 48

Fist percussion

Answer 48

identifies tenderness over kidneys, liver, & gallbladder