Chapter 22 - Assessing Patients and Managing Acute Situations

Question 1

incontinence

Answer 1

loss of bladder control

Question 2

cyanotic

Answer 2

The term cyanotic denotes a bluish coloration in the skin and indicates a lack of sufficient oxygen (O2) in the tissues. This is most easily seen on the mucous membranes, such as the lips or the lining of the mouth. Nail beds may also show a bluish tinge.

Question 3

diaphoretic

Answer 3

(perspiring) in what is frequently called a cold sweat

Question 4

Normal oral temperatures

Answer 4

vary from 96.8°F to 99.6°F (36°C to 37.6°C)

Question 5

dyspnea

Answer 5

difficulty in breathing

Question 6

tachypnea

Answer 6

extremely rapid breathing

Question 7

systolic

Answer 7

a measure of the pumping action of the heart muscle itself

Question 8

diastolic

Answer 8

indicates the ability of the arterial system to accept the pulse of blood forced into the system when the left ventricle contracts

Question 9

hypertension

Answer 9

abnormally high BP

Question 10

hypotension

Answer 10

abnormally low BP

Question 11

sphygmomanometer, often called a blood pressure cuff

Answer 11

Sphygmomanometers once measured pressure by using a mercury column that rose or fell according to the pressure. For this reason, BP is measured in units of millimeters of mercury (mm Hg). Equipment containing mercury is no longer used. Digital electronic models and aneroid manometers using air pressure have now replaced mercury units to meet OSHA requirements for eliminating mercury from the workplace.

Question 12

When nasal prongs are used,

Answer 12

the O2 flow rate should be adjusted to 4L/min or less, because higher rates are drying to the nasal mucosa.

Question 13

Oxygen Administration

Answer 13

Attach the mask to the O2 supply and adjust the flow meter to deliver 3 to 5L/min.

Question 14

Asthma

Answer 14

Asthma is difficulty in breathing caused by bronchospasm, which restricts the patient’s ability to take in a sufficient volume of air.

Question 15

Angina pectoris, often simply called angina,

Answer 15

is the term for chest pain that occurs when the coronary arteries are unable to supply the heart with sufficient O2 to meet current needs.

Question 16

erythema

Answer 16

redness of the skin

Question 17

urticaria

Answer 17

hives

Question 18

anaphylaxis or anaphylactic shock

Answer 18

A severe allergic reaction

Question 19

The earliest symptoms of anaphylaxis include

Answer 19

a sense of warmth, tingling, and itching of palms and soles. Within seconds or minutes, the patient experiences difficulty swallowing, constriction in the throat, a feeling of doom, an expiratory wheeze, and then progression into laryngeal and bronchial edema (swelling) that can block the airway completely.

Question 20

hyperventilation

Answer 20

air hunger with rapid respirations

the term for excessive breathing

These patients have breathed in too much O2 and have exhaled too much carbon dioxide, which disturbs the chemical balance of the blood.

Question 21

hyperglycemia

Answer 21

an elevated blood glucose level; it is characterized by a relatively slow onset.

Question 22

diabetic coma

Answer 22

The individual who is terribly thirsty, urinates copious amounts frequently, and has fruity-smelling breath (because of ketones excreted via the respiratory tract)

Question 23

hypoglycemia

Answer 23

a low blood glucose level

Question 24

cerebrovascular accident (CVA), also called a stroke

Answer 24

is caused by lack of adequate blood circulation to the brain.

Question 25

acronym FAST be used to help remember and identify the warning signs of a stroke:

Answer 25

*F—Face drooping: Does one side of the face droop or is it numb? Ask the person to smile. Is the smile uneven?
*A—Arm weakness: Is one arm weak or numb? Ask the person to raise both arms. Does one arm drift downward?
*S—Speech difficulty: Is speech slurred? Is the person unable to speak or hard to understand? Ask the person to repeat a simple sentence, like “The sky is blue.” Is the sentence repeated correctly?
*T—Time to call 9-1-1: If someone shows any of these symptoms, even if the symptoms go away, call 9-1-1 and get the person to a hospital immediately. Check the time so you will know when symptoms first appeared.

Question 26

Seizures may be a response to

Answer 26

drug sensitivity, infection, epilepsy, tumor, or fever. No direct, consistent correlation exists between seizures and mental acuity, emotional instability, or heredity.

Question 27

anoxia

Answer 27

a lack of O2 to the brain

Question 28

postural hypotension or orthostatic hypotension

Answer 28

A lightheaded or dizzy sensation is not unusual when patients sit up suddenly from a recumbent position. This is especially common after prolonged periods of bed rest.

Question 29

syncope

Answer 29

fainting

is a very mild form of shock that sometimes occurs when fright, pain, or unpleasant events are beyond the coping ability of the patient’s nervous system.

Question 30

Vertigo

Answer 30

a sensation of dizziness. The patient does not feel lightheaded but feels as if the room is moving or whirling.
This sensation is usually attributed either to a middle ear disturbance or to a lesion in the brain or spinal cord.

Question 31

epistaxis

Answer 31

nosebleed

Question 32

A nosebleed, or epistaxis

Answer 32

Instruct the patient to breathe through the mouth and to squeeze firmly against the nasal septum for 10minutes. The patient should not lie down, blow the nose, or talk. Provide an emesis basin or disposable emesis bag, instructing the patient to spit out blood that runs down the nasopharynx rather than swallow it.

Question 33

Shock

Answer 33

general term used to describe a failure of circulation in which BP is inadequate to support O2 perfusion of vital tissues and to remove the byproducts of metabolism.

It may be caused by blood loss, severe infection, head trauma, heart failure, or a severe allergic response. Early signs of shock are pallor, increased heart rate and respiration rate, and restlessness or confusion.

Question 34

The following symptoms, in any or all combinations, indicate some degree of shock:

Answer 34

*Restlessness and a sense of apprehension
*Increased pulse rate
*Pallor accompanied by weakness or a change in thinking ability
*Cool, clammy skin
*A fall in BP of 30mm Hg below the baseline systolic pressure or a drop in diastolic pressure below 50mm Hg