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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
Q

“skin tags” are overgrowths of normal skin in older adults

A

acrochordons

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26
Q

abnormal lung sound that occurs with pneumonia and pulmonary edema

A

crackles

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27
Q

abnormal lung sound that occurs from asthma and emphysema

A

wheezes

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28
Q

a coarse crackling sensation palpable over the skin surface

A

crepitus

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29
Q

jaundice, mongolian spots, and hemaniomas may be normal in

A

infants

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30
Q

to check for cyanosis, definitely check the

A

tongue

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31
Q

cool skin might be a sign of compromised __ or dehydration

A

circulation

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32
Q

for older adults, check skin turgor near the

A

clavicle or sternum

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33
Q

decreased turgor is a normal finding for

A

older adults

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34
Q

turgor is seen with normal aging and

A

dehydration

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35
Q

dry and flakey skin may be normal for

A

older adults

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36
Q

to check for edema, press with your finger for how many seconds

A

5

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37
Q

milia (tiny collections of sebum on the face) are normal in

A

infants

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38
Q

acrochordons are normal in

A

adults

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39
Q

flat or inverted nipples are ___ finding

A

abnormal

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40
Q

visible thyroid is a ___ finding

A

abnormal

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41
Q

an enlarged thyroid may indicate a

A

goiter

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42
Q

a tender thyroid may indicate

A

inflammation

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43
Q

sternal and intercostal retractions are seen in severe

A

hypoxia

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44
Q

touching the back and chest to feel for vibrations while the person says “99”

A

tactile fremitus

45
Q

being unable to hear tactile fremitus is the midthorax is ___ finding

A

normal

46
Q

children and thin adults may have ___ed fremitus

A

increased

47
Q

increased fremitus means the lungs are more dense, such as in

A

edema

48
Q

decreased fremitus means the lungs are less dense, such as in __ or __

A

emphysema or asthma

49
Q

percuss over the intercostal spaces rather than over the

A

ribs

50
Q

when percussing the chest, dullness indicates

A

fluid or masses in the lungs

51
Q

when percussing the chest, hyper resonance indicates air trapping, such as in

A

emphysema

52
Q

the movement of the diaphragm during breathing

A

diaphragmatic excursion

53
Q

normal distance for diaphragmatic excursion

A

3 to 6 cm

54
Q

decrease diaphragmatic excursion may indicate

A

paralysis, atelectasis, or COPD

55
Q

bronchial breath sounds are heard over the

A

trachea

56
Q

bronchovesicular breath sounds are heard over the __ and between the __

A

sternum and between scapulae

57
Q

vesicular breath sounds are heard over

A

most of the lung fields

58
Q

crackles are aka

A

rales

59
Q

abnormal breath sound, bubbling, popping, very brief and heard during inspiration

A

crackling

60
Q

abnormal breath sound, snoring, continuous low pitched. May clear with coughing

A

rhonchi

61
Q

abnormal breath sound, musical or squeaking

A

wheezes

62
Q

abnormal breath sound, honking

A

stridor

63
Q

abnormal breath sound, grating

A

friction rub

64
Q

abnormal breath sound, high pitched tubular sound

A

grunting

65
Q

nurse needs to be notified is PO falls below

A

95%

66
Q

postural drainage should not be done for at least 2 hours after

A

eating

67
Q

ulcer that has irregular wound pattern

A

venous

68
Q

type of ulcer- surrounding skin it thin, shiny, dry, cool, loss of hiar

A

arterial

69
Q

type of ulcer, patients complain of increasing pain with activity

A

arterial

70
Q

between arterial and venous, which has a pale base and which is “ruddy/beef”

A

arterial pale

venous “ruddy/beefy”

71
Q

cane size: with patient standing, place the cane 4 inches from her foot. It should come up to the __ of the hip joint

A

top

72
Q

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

A

30

73
Q

crutch size: while the pt is wearing shoes, measure from the heal to the axilla then add

A

1 inch (2.5 cm)

74
Q

crutches: have pt stand and place crutches 4 to 6 inches (10 to 15 cm) from his

A

heel

75
Q

crutches: adjust the axillary pad __ fingerbreadths below the axilla

A

3

76
Q

the pt should hold the cane on his __ side

A

strong

77
Q

cane: distribute weight __ between feet and cane

A

evenly

78
Q

advance the cane and __ leg at the same time.

A

weaker

79
Q

where do you stand with a walker?

A

between the back legs

80
Q

pick up the walker and advance it as you

A

step ahead

81
Q

similar to using a cane, when you advance the walker also advance the ___er leg

A

weaker

82
Q

3 factors used in the Braden score of pressure ulcers

A

mobility
nutrition/hydration
moisture

83
Q

__ cream is used to treat incontinence dermatitis

A

barrier

84
Q

which abnormal findings should be escalated?

A

all

85
Q

if someone’s at risk for pressure ulcers check their nutrition status, specifically __ level

A

albumin

86
Q

if someone’s at risk for pressure ulcers, besides albumin check their __ and __

A

BUN and hemoglobin

87
Q

skin redness can be a stage 1 pressure ulcer or

A

DTI

88
Q

__ gel is used for keeping the wound moist

A

hydrogel

89
Q

you have to wound so that it doesn’t form an

A

abscess

90
Q

use of heat and cold requires an

A

order

91
Q

type of wound healing: when a wound involves minimal or no tissue loss and has edges that are well approximated (closed)

A

primary intention healing

92
Q

type of wound healing: occurs when a wound involves extensive tissue loss, which prevents wound edges from approximating

A

secondary intention healing

93
Q

type of wound healing: occurs when a wound should not be closed (e.g. because it’s infected)

A

secondary intention healing

94
Q

type of wound healing: occurs when 2 surfaces of granulation tissue are brought together

A

tertiary intention healing

95
Q

type of wound healing: requires strict aseptic technique

A

tertiary intention healing

96
Q

clean wounds typically drain __ exudate

A

serous

97
Q

exudate: watery, straw colored

A

serous

98
Q

exudate often seen with deep wounds or wounds or wounds in highly vascular areas

A

sanguineous

99
Q

exudate that indicates damage to capillaries

A

sanguineous

100
Q

exudate in new wounds

A

serosanguineous

101
Q

malodorous exudate

A

purulent

102
Q

exudate seen with infected wounds

A

purulent

103
Q

red pus exudate

A

purosanguineous

104
Q

between venous and arterial ulcers, which has drainage

A

venous

105
Q

if the tissue was compressed for 1 hour, reactive hyperemia should not last longer that

A

30 minutes (if it lasts longer than 30 minutes, there’s been tissue damage)

106
Q

adequate intake of calories, protein, vitamin C, and zinc and cholesterol, copper are need to promote

A

healing

107
Q

fever can be a risk factor for

A

skin breakdown

108
Q

6 rights

A 
patient
medication
dose
route
time
documentation

aa Orgo (196 decks)

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