301 Test 1 power points Part 3

Question 1

assessment type that Gathers system-related data all at once

Answer 1

Systems approach

Question 2

3 Types of health assessment

Answer 2

Systems approach
Head to toe
Functional pattern approach

Question 3

Ndx will only include s/s if it’s an ___ problem

Answer 3

actual problem

Question 4

If you do not know the etiology indicate r/t

Answer 4

”?” Or “unknown”

Question 5

assessment that focuses on strengths and weaknesses

Answer 5

Functional health pattern

Question 6

Correct sequence of the 4 techniques used in assessment

Answer 6

Inspection
Palpation
Percussion
Auscultation (except for abdominal assessment: second after inspection)

Question 7

> 35 inches in women and __ inches in men increases the risk for type 2 diabetes, dyslipidemia, hypertension, and CVD

Answer 7

40

Question 8

“5th vs”

Answer 8

pain

Question 9

Thigh BP is ___er than in the arm

Answer 9

higher

Question 10

coarctation of aorta

Answer 10

narrowing

Question 11

main relay station for incoming stimuli

Answer 11

Thalamus

Question 12

part of brain: temperature, sleep, emotions, autonomic activity, pituitary gland

Answer 12

hypothalamus

Question 13

muscle coordination, equilibrium

Answer 13

Cerebellum

Question 14

motor neurons, motor and sensory tract

Answer 14

Midbrain and pons

Question 15

respiration, heart, GI function

Answer 15

Medulla

Question 16

Any change in mental status requires

Answer 16

escalation of care to the physician

Question 17

Tactile discrimination

Answer 17

Stereognosis
Graphesthesia
Two-point discrimination
Extinction
Point location

Question 18

brief involuntary twitching of muscle group

Answer 18

Myoclonus

Question 19

muscle twitch (small area)

Answer 19

Fasciculations

Question 20

an abnormal involuntary movement disorder

Answer 20

Chorea or Athetosis

Question 21

Declines associated with normal aging:
Diminished ability to learn ___ information
Delayed __ time
Minor loss of recent __

Answer 21

complex
response
memory

Question 22

Pathological conditions of impaired cognitive function

3 Ds

Answer 22

Depression
Delirium
Dementia

Question 23

clinical syndrome characterized by lower mood tone, difficulty thinking, and somatic changes precipitated by feelings of loss and/or guilt. These symptoms represent a change from usual functioning for the individual that have been present for at least 2 weeks.

Answer 23

Depression

Question 24

disturbance of consciousness with impaired attention and disorganized thinking that develops rapidly. Evidence of an underlying physiologic or medical condition is generally present.

Answer 24

Delirium

Question 25

a syndrome of cognitive deterioration that involves memory impairment and disturbance in at least one other cognitive area that results in changes in function (e.g. aphasia, apraxia, or agnosia) and behavior.

Answer 25

Dementias (e.g. Alzheimer’s or vascular)

Question 26

The most common risk factors associated with delirium are:

Answer 26

Dementia Male gender Advanced age Medical illness

Question 27

Predisposing factors associated with delirium are:

Answer 27

``` Poor functional status Alcohol abuse Depression Dehydration Sensory impairment ```

Question 28

delirium vs dementia, Short, rapid, hours/days

Answer 28

delirium

Question 29

delirium vs dementia, Vague symptoms, loss of intellect, agitated, aggressive

Answer 29

dementia

Question 30

delirium vs dementia, Easily distracted, inappropriate anxiety, labile to apathy

Answer 30

dementia

Question 31

delirium vs dementia, Labile variable fear/panic, euphoria, disturbed

Answer 31

delirium

Question 32

easiest colors for old ppl to see are

Answer 32

yellow red orange

Question 33

Older adults have a decreased ___ of taste buds

Answer 33

number

Question 34

Put on PPE beginning with

Answer 34

cap

Question 35

Next put on gown with opening in

Answer 35

back

Question 36

Gloves go on __ with cuffs of gown tucked into gloves

Answer 36

last

Question 37

Bathing- wash from fingers to

Answer 37

Axilla

Question 38

Moving pt: Use __ ppl if pt is more than 200 lbs

Answer 38

3

Question 39

Risk for injury: | ___ conditions interacting with client’s adaptive and defensive resources

Answer 39

Environmental

Question 40

Risk for thermal injury: | ___ impairment, inadequate supervision, developmental level

Answer 40

Cognitive

Question 41

A client with the Dx Risk for Injury is diagnosed with Ineffective Protection if they are at risk for

Answer 41

bleeding

Question 42

When it comes to reducing injury, be extra careful with patients on what kind of medication

Answer 42

Blood thinner

Question 43

you can disconnect IV if it has a

Answer 43

2 way connector

Question 44

Wash arm with long strokes from __ to __

Answer 44

distal to prox

Question 45

Dont massages ___ because that cold dislodge a clot causing an embolis

Answer 45

calves

Question 46

Dont apply lotion between the

Answer 46

toes

Question 47

A back rub may be contraindicated for pts with

Answer 47

CV disease

Question 48

Cannot delegate foot care to NAP if pt has foot ulcers or impaired peripheral

Answer 48

circulation

Question 49

Pts who have DM or impaired circulation require Rx for trimming

Answer 49

nails

Question 50

During foot care, if pt can't sit up put in __ __ position

Answer 50

semi fowler position

Question 51

Soaking feet is contraindicated for pts with __ or __ __ disease

Answer 51

DM or peripheral vascular disease

Question 52

For oral care, pt should be in chair or in __ __ position

Answer 52

high fowler

Question 53

Move floss __ and __ instead of back and forth

Answer 53

up and down

Question 54

oral thermometer tip is what color

Answer 54

blue

Question 55

immediately report temp if greater than

Answer 55

100

Question 56

oral temp can be affected by eating, smoking, drinking, and

Answer 56

chewing gum

Question 57

If pt was lying on her side, do not take __ __ temp on the side that was on the pillow

Answer 57

temporal artery

Question 58

For ear temp for an adult, pull pinna __ and back

Answer 58

up

Question 59

If you have trouble getting the brachial pulse you can ask pt to

Answer 59

turn palm downward

Question 60

pulse site used for CPR for an infant

Answer 60

brachial

Question 61

Which pulse may be difficult in old ppl

Answer 61

foot

Question 62

Where do you palpate posterior tibial pulse

Answer 62

ankle

Question 63

apical HR must be counted for

Answer 63

1 min

Question 64

digitalis therapy, blood loss, cardiac or resp disease, and other thing that affect oxygenation status may warrant taking a __ __ __ __

Answer 64

apical-radial pulse deficit

Question 65

The presence of any apical-radial pulse is

Answer 65

abnormal

Question 66

when taking BP, palm faces

Answer 66

upward

Question 67

A difference of 10 is normal when comparing BP in

Answer 67

left and right arms

Question 68

Tuning fork is used to assess

Answer 68

deep sensation

Question 69

kinesthetic sense is

Answer 69

position

Question 70

ability to recognize an object by touch

Answer 70

stereognosis

Question 71

Able to recognize something written on the skin

Answer 71

graphesthesia

Question 72

Normal deep tendon reflex rating

Answer 72

+2

Question 73

The MMSE focuses only on ___, not mood or thought process

Answer 73

cognitive

Question 74

transitioning btwn state of lethargy and stupor

Answer 74

obtunded

Question 75

normal temp range for adult

Answer 75

96 to 99

Question 76

oral temp is 1 degree lower than

Answer 76

rectal

Question 77

HR in older adults is ___er

Answer 77

slower

Question 78

The romberg assessment tests

Answer 78

balance

Question 79

most important factor in neuro check

Answer 79

level of consciousness

Question 80

abnormally low systolic

Question 81

abnormally low diastolic