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aa Orgo > 301 Test 2 part 2 > Flashcards

301 Test 2 part 2 Flashcards

1
Q

a related factor to acute confusion is being over the age of

A

60

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2
Q

a few of the precipitating factors of acute confusion:

A

use of restraints
indwelling catheter
hospital admission for fractures of hip surgery
male gender

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3
Q

foul smelling sputum and fever can be signs of

A

risk for aspiration

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4
Q

moles that are greater than __ mm are cause for concern

A

6 mm

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5
Q

most reliable site to exam color change in dark skinned people

A

under tongue, buccal mucosa, palpebral conjunctiva, sclera

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6
Q

localized hypothermia occurs in peripheral arterial insufficiency and in ___ disease because of vasospasm

A

Raynauds disease

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7
Q

warm, moist, velvet skin is associated with

A

hyperthyroidism

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8
Q

rough, dry skin is associated with

A

hypothyroidism

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9
Q

arterial insufficiency makes the skin very

A

thin and shiny

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10
Q

a deep pitting edema would get a rating of

A

+4

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11
Q

unilateral edema suggests a peripheral problem where as bilateral suggests a central such as __ or __ failure

A

heart of kidney

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12
Q

poor turgor can indicate severe

A

dehydration

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13
Q

small red dots on adults

A

cherry (senile) angiomas (they’re not significant)

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14
Q

seborrhea is aka

A

dandruff

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15
Q

spoon shape nails may occur with

A

iron deficiency anemia

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16
Q

inflammation of the base of the nail

A

paronychia

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17
Q

a normal angle for a nail is

A

160 degrees

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18
Q

thick and ridged nails can be caused by arterial

A

insufficiency

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19
Q

brown linear streaks along the nail are abnormal for

A

light skinned people

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20
Q

a sluggish capillary refill is slower that

A

1 to 2 seconds

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21
Q

in pregnant women, on the abdomen the linea __ appears as a brownish-black line

A

nigra

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22
Q

an irregular brown patch on the face (normal finding)

A

chloasma

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23
Q

lesions in pregnant women with tiny red centers and radiating branches

A

vascular spiders

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24
Q

liver spots are aka senile

A

lentigines

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25
"skin tags" are overgrowths of normal skin in older adults
acrochordons
26
abnormal lung sound that occurs with pneumonia and pulmonary edema
crackles
27
abnormal lung sound that occurs from asthma and emphysema
wheezes
28
a coarse crackling sensation palpable over the skin surface
crepitus
29
jaundice, mongolian spots, and hemaniomas may be normal in
infants
30
to check for cyanosis, definitely check the
tongue
31
cool skin might be a sign of compromised __ or dehydration
circulation
32
for older adults, check skin turgor near the
clavicle or sternum
33
decreased turgor is a normal finding for
older adults
34
turgor is seen with normal aging and
dehydration
35
dry and flakey skin may be normal for
older adults
36
to check for edema, press with your finger for how many seconds
5
37
milia (tiny collections of sebum on the face) are normal in
infants
38
acrochordons are normal in
adults
39
flat or inverted nipples are ___ finding
abnormal
40
visible thyroid is a ___ finding
abnormal
41
an enlarged thyroid may indicate a
goiter
42
a tender thyroid may indicate
inflammation
43
sternal and intercostal retractions are seen in severe
hypoxia
44
touching the back and chest to feel for vibrations while the person says "99"
tactile fremitus
45
being unable to hear tactile fremitus is the midthorax is ___ finding
normal
46
children and thin adults may have ___ed fremitus
increased
47
increased fremitus means the lungs are more dense, such as in
edema
48
decreased fremitus means the lungs are less dense, such as in __ or __
emphysema or asthma
49
percuss over the intercostal spaces rather than over the
ribs
50
when percussing the chest, dullness indicates
fluid or masses in the lungs
51
when percussing the chest, hyper resonance indicates air trapping, such as in
emphysema
52
the movement of the diaphragm during breathing
diaphragmatic excursion
53
normal distance for diaphragmatic excursion
3 to 6 cm
54
decrease diaphragmatic excursion may indicate
paralysis, atelectasis, or COPD
55
bronchial breath sounds are heard over the
trachea
56
bronchovesicular breath sounds are heard over the __ and between the __
sternum and between scapulae
57
vesicular breath sounds are heard over
most of the lung fields
58
crackles are aka
rales
59
abnormal breath sound, bubbling, popping, very brief and heard during inspiration
crackling
60
abnormal breath sound, snoring, continuous low pitched. May clear with coughing
rhonchi
61
abnormal breath sound, musical or squeaking
wheezes
62
abnormal breath sound, honking
stridor
63
abnormal breath sound, grating
friction rub
64
abnormal breath sound, high pitched tubular sound
grunting
65
nurse needs to be notified is PO falls below
95%
66
postural drainage should not be done for at least 2 hours after
eating
67
ulcer that has irregular wound pattern
venous
68
type of ulcer- surrounding skin it thin, shiny, dry, cool, loss of hiar
arterial
69
type of ulcer, patients complain of increasing pain with activity
arterial
70
between arterial and venous, which has a pale base and which is "ruddy/beef"
arterial pale venous "ruddy/beefy"
71
cane size: with patient standing, place the cane 4 inches from her foot. It should come up to the __ of the hip joint
top
72
walker size: should extend from the floor to the hip joint so that the patient can hold the walker with __ degree flexion of the elbow
30
73
crutch size: while the pt is wearing shoes, measure from the heal to the axilla then add
1 inch (2.5 cm)
74
crutches: have pt stand and place crutches 4 to 6 inches (10 to 15 cm) from his
heel
75
crutches: adjust the axillary pad __ fingerbreadths below the axilla
3
76
the pt should hold the cane on his __ side
strong
77
cane: distribute weight __ between feet and cane
evenly
78
advance the cane and __ leg at the same time.
weaker
79
where do you stand with a walker?
between the back legs
80
pick up the walker and advance it as you
step ahead
81
similar to using a cane, when you advance the walker also advance the ___er leg
weaker
82
3 factors used in the Braden score of pressure ulcers
mobility nutrition/hydration moisture
83
__ cream is used to treat incontinence dermatitis
barrier
84
which abnormal findings should be escalated?
all
85
if someone's at risk for pressure ulcers check their nutrition status, specifically __ level
albumin
86
if someone's at risk for pressure ulcers, besides albumin check their __ and __
BUN and hemoglobin
87
skin redness can be a stage 1 pressure ulcer or
DTI
88
__ gel is used for keeping the wound moist
hydrogel
89
you have to wound so that it doesn't form an
abscess
90
use of heat and cold requires an
order
91
type of wound healing: when a wound involves minimal or no tissue loss and has edges that are well approximated (closed)
primary intention healing
92
type of wound healing: occurs when a wound involves extensive tissue loss, which prevents wound edges from approximating
secondary intention healing
93
type of wound healing: occurs when a wound should not be closed (e.g. because it's infected)
secondary intention healing
94
type of wound healing: occurs when 2 surfaces of granulation tissue are brought together
tertiary intention healing
95
type of wound healing: requires strict aseptic technique
tertiary intention healing
96
clean wounds typically drain __ exudate
serous
97
exudate: watery, straw colored
serous
98
exudate often seen with deep wounds or wounds or wounds in highly vascular areas
sanguineous
99
exudate that indicates damage to capillaries
sanguineous
100
exudate in new wounds
serosanguineous
101
malodorous exudate
purulent
102
exudate seen with infected wounds
purulent
103
red pus exudate
purosanguineous
104
between venous and arterial ulcers, which has drainage
venous
105
if the tissue was compressed for 1 hour, reactive hyperemia should not last longer that
30 minutes (if it lasts longer than 30 minutes, there's been tissue damage)
106
adequate intake of calories, protein, vitamin C, and zinc and cholesterol, copper are need to promote
healing
107
fever can be a risk factor for
skin breakdown
108
6 rights
``` patient medication dose route time documentation ```

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