307 final Flashcards
What tests are commonly used for attention and concentration
Digit span (recite a series of numbers asking the patient to repeat them )
Serial 7s (start from 100, subtract 7 and keep subtracting 7…)
Spelling backwards (say a 5 letter world, spell it and then ask patient to spell it backwards)
Using an audioscope to assess hearing in an older adult patient, what dB is it set to
40dB
The 10 minute geriatric screener assesses what 3 domains
Physical, cognitive, and psychosocial
What is the scoring of the audit-c screening mean
Higher= more likely that drinking affects the persons life
4 or higher in male = positive
3 or higher in women = positive
What is performed during a general survey exam
Apparent state of health
Level of consciousness
Facial expressions
Posture, gait, motor activity and speech
Odors of breath and body
Skin color and obvious lesions
Dress, grooming hygiene
Signs of distress
Central cyanosis in infants suggests what
Congenital cardiac abnormalities as well as respiratory diseases
(It is always abnormal)
Acrocyanosis in infants is what?
Common appearance of bluish hands or feet shortly after birth is normal
Tachypnea, tachycardia, and hematomegaly in infants suggests what?
Congestive heart failure
A diffuse bulge outward of the left side of an infants chest suggest what?
Long standing cardiomegaly (an enlarged heart)
The most common dysrhythmia in infants is what
PSVT (paroxysmal supraventricular tachycardia) or
Paroxysmal atrial tachycardia (PAT)
They the same thing.
Fourth heart sounds in children suggest what
Congestive heart failure
(Decreased ventricular compliance)
Facial characteristics of a child presenting with short palpebral fissures, wide flattened philtrum (vertical upper lip groove), and thin lips suggests what?
Fetal alcohol syndrome
What is echolalia
Repetition of words and phrases of others.
Common in toddlers
If happens past 3 years of age, suspect speech or developmental delay
Also indicates manic episodes or schizophrenia
What is the PLISS IT model?
Used to initiate discussion of sex
P=Permission from client to talk about it
LI= limited information needed provided
SS= specific suggestions given to client
IT= intensive therapy provided surrounding issues of sexuality for client.
What is the DRIP used for
To assess transient causes of incontinence in elderly
D= delirium
R= restricted mobility
I= infection, inflammation, impaction
P= polyuria, pharmaceuticals
Older adults (over 65) should have no more than how many drinks?
3 drinks on any one day or
7 drinks a week.
Hypothermia is more common in adults t/f
T
What is the single most common modifiable risk factor associated with falls
Medications
Instrumental activities of daily living
Using the phone
Shopping
Preparing food
Housekeeping
Laundry
Driving
Taking medication
Managing money
Physical ADLs
Bathing
Dressing
Toileting
Transferring
Continence
Feeding
SPICES
Is what?
Sleep disorders
Problems with eating or feeding
Incontinence
Confusion
Evidence of falls
Skin breakdown
A tool to assess geriatric syndromes related to functional decline
In older adults an S3 sound suggests what
Heart failure
an S4 sound can be heard in healthy older adults. T/f
True. Often suggests decrease ventricular compliance and impaired filling though.
Middle aged and older adults commonly have what kind of murmur?
Systolic aortic murmur.
Tanner stages in girls
Sexual maturity of breasts and pubic hair.
Stage 1 preadolescent
2-=11-12 yrs
3= 12-13
4= 13-15
5= older than 15
Normal onset of breast development is called what
Thelarche
Tanner Sexual maturity rating in boys
Stage 1= preadolescent
2= 11.5-12.5 yrs
3= 12.5-13.5
4= 13.5-15
5= older than 15
When testing for scoliosis an angle greater than what would be reason for concern and referral to specialist?
7 degrees
Risky behaviors in adolescence assessment tool
HEEADSSS
Home
Education/employment
Eating
Activities
Drugs/alcohol
Sexuality
Suicide/depression/self harm
Safety from injury and violence
At what age would you ask the parent to leave the room for part of the interview with a child
10-11
Common childhood infection presenting with erythema of posterior pharynx and palatal petechiae and a foul smelling exudate.
Strep throat
Strawberry tongue, white or yellow exudate on tonsils, beefy red uvula and palatal petechiae would indicate what
Strep throat.
Pale, boggy nasal mucous membranes are found in children suggest what?
Chronic (perennial) allergic rhinitis
How far into the ear canal do you insert the otoscope speculum?
1/4-1/2 inch
You can hold the otoscope with the handle up or with the handle down.
T/f
True
What is the best single finding for ruling out pneumonia?
Absence of tachypnea
Heart rate of less than 100 bpm in infants and toddlers indicates what
Sinus bradycardia
Respiratory rates in children over 1 year old greater than 40 breaths per minute is what
Tachypnea
A pulse rate too rapid to count in an infant (greater than 180/min) may indicate what
Paroxysmal supraventricular tachycardia
A patient being treated with prostaglandin analog for open angle glaucoma has an IOP of less than 21mmHg. This indicates what?
Medication is effective
After Lasik surgery, glaucoma may be present even if IOP is normal
T/f
True
Athetosis is what
Slow twisting and writhing of fingers and hands. Causes include cerebral palsy
Pinpoint pupils in a comatose patient means
Pons hemorrhage or narcotic effects
Aphonia is what
Loss of voice
Laryngitis, vocal cord paralysis (CN X) laryngeal tumor.
Dysarthria is what
Defect in muscle control of speech
(Lips, tongue, palate & pharynx. )
Motor lesion of central and peripheral nervous system. Parkinson’s and cerebral disease
Apisia is what
A disorder in producing or understanding language.
Lesion in dominant cerebral hemisphere (usually left)
eye response scoring for glasgow coma scale
spontaneous = 4
to speech= 3
to pain= 2
not= 1
verbal response for glasgow coma scale
A&O x4 = 5
confused=4
inappropriate verbal response= 3
incomprehensible sounds = 2
none=1
motor response for glasgow coma scale
obeys commands = 6
moves to localized pain= 5
withdrawas from painful stimuli= 4
abnormal flexion= 3
abnormal extension =2
none= 1
comatose clients would rate what on the glasgow scale
8 or less (sever brain injury)
glasgow rating of 9-12 means
moderate brain injury
If a person can write a correct sentence can they still have apashia?
No
A person who scores less than 17 points on a mini mental state exam would indicate what?
Severe cognitive impairment
30 is the max points as cognition declines, so does score.
What is the PHQ used to screen?
Patient health questionnaire is used to screen for depression
What screening tools are used for depression
PHQ
Geriatric depression scale
EDS (Edinburgh postnatal depression scale)
SAFE-T evaluates what?
Suicide risk
What is anhedonia?
Not finding pleasure in daily activities
Clients most at risk for depressive symptoms would include
Females
Divorced or single
Chronically Ill
Young
Bereaved
Prior or family history of depression
What is confabulation
Fabrication of facts or events in response to questions, to fill in the gaps of an impaired memory.
Often seen in Korsakoff syndrome from alcoholism, dementia, schizophrenia, aphasia or psychotic disorders.
Korsakoff syndrome is what
A memory disorder results from vitamin B1 deficiency associated with alcoholism.
Derailment is what
Tangential speech with shifting topics that are loosely connected or unrelated. Seen with schizophrenia
Neologisms are what
Invented or distorted words
Words with new and highly idiosyncratic meanings.
Occurs with Korsakoff syndrome from alcoholism.
Metabolic syndrome risk factors include
Large waist circumference (m> 40, f> 35)
High blood pressure >130/85
High fasting blood sugar 100mg/dL
High triglycerides 150mg/dL or higher
What cranial nerve is involved with chewing
Trigeminal
What are somatic symptoms
Physical symptoms that are medically unexplained and generally coexist with depression or anxiety disorders.
Chronic pain …
(Box 19-3 pg 693)
What is pertussis
Paroxysmal cough with a whoop at the end.
Vaccine preventable.
Developmental tasks phases can be broken up into 4 categories. What are they
Physical
Cognitive
Social identity
Independence
A 6 year old child presents with a venous hum. What does the nurse suspect
It is considered a benign heart murmur.
Laxity of the soft tissue structures of the foot can cause what in young children
Pes planus
While performing cardiac auscultation of a hound child, the nurse detects a pulmonary flow murmur that is accompanied by a fixed split second heart sound. What does this suggest.
Right heart volume load
A newborn is diagnose with coarctation of the aorta. When taking the bp, the nurse would expect it to reflect
Sustained hypertension
Breast development of a 13 yr old where breasts and nipples appear as small mounds with areolar development evident. What stage of maturity is this
Stage 2
Denver 2 test is what
Developmental test to measure 6 mo milestones
Congenital dermal melanocytosis is what
Can be a birthmark on an African American child, A black and blue mark.
A 15 yr old male has tested and scrotum that are enlarged and scrotal skin is darkened. His pubic hair is course and curly but does not extend to the thighs. What tanner stage is this?
Stage 4
Idiopathic scoliosis is usually seen in girls and is in what percentage of cases?
75%
After the age of 2 how much do toddlers grow per year?
About 5cm
And 2-3kg gained
When examining visual acuity on a 30-month old the nurse should assess for what?
Fixation preferences.
Children with poor vision will object to having the good eye covered.
When examining the tympanic membrane of a 4-year old the nurse would pull the auricle ___________ after placing otoscope in ear canal
Down and backward
What is helpful in Measuring older children, especially if the child is suspected of having endocrine disorders?
Velocity growth curves.
Aortic stenosis would sound like what
Murmur heard over the aorta while patient is on the left lying side. (Or leaning forward??) ahhhh. Idk
