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Fundamentals of Nursing > Cranial Nerves/Nursing Process/Infection control/General survey > Flashcards

Cranial Nerves/Nursing Process/Infection control/General survey Flashcards

1
Q

Increase in neutrophils may be due to

A

Acute infection
Stress
Gout
Trauma

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2
Q

Normal ranges for monocytes

A

5-10%

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3
Q

Droplet Precautions

A

Ex: Meningitis, pneumonia, influenza, mumps, rubella
Mask and private room
Doors may remain open

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4
Q

Cranial Nerve VII (7)

A

Facial ( smile, frown, puff cheeks, speech, taste, close eyes)

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5
Q

Double Effect

A

Principle that may justify some actions that produce both god and evil effects
(The action itself is good, Good is not achieved by means of evil effect)

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6
Q

Objective data in appearance

A

Posture
Body movements
Dress
Grooming and hygiene

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7
Q

Cranial nerve IX (9)

A

Glossopharyngeal

Swallowing, taste, gag reflex

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8
Q

Murphy’s sign

A

Palpate liver while pt take in deep breath. Sharp pain with no inhalation
Possible cholecystitis

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9
Q

Rinne test

A

Tuning fork at the mastoid process then in front of auditory meatus
AC>BC

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10
Q

Secondary Preventative care

A

Health maintenance aimed at early detection, prevent or minimize loss of function and independence
(health screenings)

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11
Q

Bruit

A

Blowing/swoshing sound= obstruction

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12
Q

Cranial nerve XII (12)

A

Hypoglossal (controls tongue muscles)

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13
Q

Stage 3 ulcer

A

Subcutaneous skin broken

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14
Q

Cerebullar function

A

Coordination and balance

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15
Q

Decorticate Rigidity

A

Bent arms towards chest
Clenched fists, held on chest
Legs straight
(Seen in pts with brain damage, brain stem tumor, head injury)

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16
Q

Examples of direct care

A

Med admin
Insert IV fusion
ADL’s
Teaching, counseling

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17
Q

Organs in RLQ

A 
Cecum
Appendix
Portion of ascending colon
Ovary
Uterine tube
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18
Q

Cranial Nerve VIII

A

Acoustic (hearing and balance)

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19
Q

Primary preventative care

A

True prevention
Health promotion/education
Teaching healthy lifestyles

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20
Q

Opsthotonos

A

Rigid
Head thrown backward
arches back
(Infants w/ meningitis, Pt w/ brain tumor, seizures, severe head injury, growth hormone deficiency, subarachnoid hemorrhage)

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21
Q

Four systematic checks of emotional and cognitive functioning

A

A. Appearance
B. Behavior
C. Cognition
D, Thought process

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22
Q

Organs in LLQ

A

Sigmoid colon
Portion of descending colon
Ovary
Uterine tube

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23
Q

Breaking chain of infection for resevoir

A 
Handwashing
Sterilize
Disinfect
Clean w/ soap and water
Dressing change
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24
Q

Breaking chain of infection for vehicle

A 
Handwashing
Trash incenerators
Linen/toiletries 
Sterilization
Sharps
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25
Organs is RUQ
Liver Gallbladder Head of pancreas Portion of right kidney
26
Tertiary level of care
Permanent and irreversible Treating condition (Meds, diet) Minimize deterioration and improving quality of life (rehab)
27
Midline
Aorta Bladder Uterus
28
Beneficence
Duty to do good and the active promotion of good/kind acts
29
Cranial nerve II (2)
Optic (visual acuity, visual field)
30
Airborne precautions
Ex: TB, measles, chickenpox Private negative pressure room Keep doors closed
31
Decerebrate Rigidity
Arms and legs held straight out Toes pointed downward Head and neck arched backwards (Severe brain damage, stroke, encephalopathy, head injury)
32
Cranial nerves for EOM
3. Occulomotor 4. Trochlear 6. Abducens
33
Whisper test
Cover one ear , stand 1-2 feet away, slowly whisper two syllable words (ex.Tuesdsay) have pt repeat each word
34
Definition of nursing
The protection, promotion, and optimization of health abilities, prevention of illness and injury, alleviation of suffering, thru the dx and treatment of human response and advocacy in the care of individuals, families, communities and populations
35
Epidermis
Thin, tough, protective barrier Major ingredient: Keratin, melanin Replaced every 4 weeks
36
Temp is controlled by
Hypothalamus
37
Key concepts of Health belief model
``` Perceived susceptibility Perceived severity Perceived benefits Perceived barriers Cues to action self efficacy ```
38
Breaking chain of infection for portal of entry
``` Handwashing Clean, dry skin, Prevent skin breakdown Clean dry linens Wound care ```
39
Elevated ESR may mean
Anemia Lupus Rheumatoid arthritis Bone infections
40
ESR tests for
inflammation in the body
41
Cranial nerve I
Olfactory (smell)
42
Organs in LUQ
``` Spleen Stomach Pancreas Portion of left kidney Left adrenal gland ```
43
Nursing process
``` Assessment Diagnosis Planning Implementation Evaluation ```
44
Stage 4 ulcer
Muscle, tissue and bone visible
45
First cells to arrive at site where inflammation occur
Neutrophils
46
Stage one ulcer
Skin red and unbroken
47
Cranial nerve X (10)
Vagus ( talking, swallowing, carotid reflex)
48
Stage 2 ulcer
Skin with epidermal and dermal injury
49
Glasgow coma scale
Used to describe LOC following traumatic brain injury. Measures eye opening, verbal and motor response 15 point scale
50
Autonomy
Right of pt to receive adequate and accurate info to make a choice free from external constraints
51
Cranial nerve V (5)
Trigeminal ( muscles of mastication, sensation of face and scalp)
52
What is "mental status"
A persons emotional and cognitive functioning
53
Breaking chain of infection for Portal of exit
``` Handwashing Waste disposal Secretions/drainage Protect open wounds Gloves/masks Medication ```
54
Cranial nerve III (3)
Occulomotor (PERRLA, raise eyelids, pupil constriction, lens shape)
55
Contact precautions
Most frequent mode of transmission Ex: Hep A, herpes, C.Diff Gloves, gown, private room in addition to standard precautions
56
Four components of wellness
Capacity to perform Ability to adjust Reports feeling of well being Feeling that everything is together
57
Sensory function
Pressure, pain and temp
58
Diurinal cycle
Temperature is lower in the morning and higher in the late afternoon
59
Anisocoria
Unequal pupil size. May be caused b aneurysm, brain tumor, increased ICP, infection of membranes around the brain ex meningitis, encephalitis
60
Cranial nerve IV (4)
Trochlear (downward and inward movement of the eye)
61
General survey
Physical appearance Body structure Mobility Behavior
62
Rovsing's sign
Pain in RLQ during pressure in LLQ. Sign of appendicitis, or peritoneal irritation
63
Cranial nerve XI (11)
Spinal (controls muscles in the head/neck/shoulders)
64
Nonmaleficence
Duty to not inflict harm
65
Blumberg's sign
Abdominal wall is compressed slowly and then rapidly released. Indicative of peritonitis
66
Maslows Hierarchy of needs
``` Self actualization Esteem and self respect Belongingness and affection Safety and security Basic needs ```
67
Objective data in Behavior
LOC Facial expression Speech Mood and affect
68
Chain of infection
``` Infectious agent Resevoir Portal of exit mode of transmission Portal of entry Susceptible hose ```
69
Breaking chain of infection for susceptible host
``` Handwashing rest skin care nutrition/fluids Immunization ```
70
Functions of skin
``` Prevent loss of water and electrolytes Regulate body heat Produce vitamin D Wound repair Excretion ```
71
Psoas sign
Right hand above right knee, raise leg against resistance, flexion of hip causes contraction of psoas muscle. appendicitis?
72
Pectus excavatum
Funnel chest
73
Pectus carinatum
pigeon chest
74
Rust/dark red sputum
TB, pneumonia, pnemococcal
75
Yellow/green sputum
lung infection
76
Hemoptysis
URI | bronchitis
77
Genum varum
bow legs
78
Genum valgum
knock knees

Fundamentals of Nursing (12 decks)

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