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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
Q

Organs is RUQ

A

Liver
Gallbladder
Head of pancreas
Portion of right kidney

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26
Q

Tertiary level of care

A

Permanent and irreversible
Treating condition (Meds, diet)
Minimize deterioration and improving quality of life (rehab)

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27
Q

Midline

A

Aorta
Bladder
Uterus

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28
Q

Beneficence

A

Duty to do good and the active promotion of good/kind acts

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29
Q

Cranial nerve II (2)

A

Optic (visual acuity, visual field)

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30
Q

Airborne precautions

A

Ex: TB, measles, chickenpox
Private negative pressure room
Keep doors closed

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31
Q

Decerebrate Rigidity

A

Arms and legs held straight out
Toes pointed downward
Head and neck arched backwards
(Severe brain damage, stroke, encephalopathy, head injury)

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32
Q

Cranial nerves for EOM

A
  1. Occulomotor
  2. Trochlear
  3. Abducens
33
Q

Whisper test

A

Cover one ear , stand 1-2 feet away, slowly whisper two syllable words (ex.Tuesdsay) have pt repeat each word

34
Q

Definition of nursing

A

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
Q

Epidermis

A

Thin, tough, protective barrier
Major ingredient: Keratin, melanin
Replaced every 4 weeks

36
Q

Temp is controlled by

A

Hypothalamus

37
Q

Key concepts of Health belief model

A 
Perceived susceptibility
Perceived severity
Perceived benefits
Perceived barriers
Cues to action
self efficacy
38
Q

Breaking chain of infection for portal of entry

A 
Handwashing
Clean, dry skin,
Prevent skin breakdown
Clean dry linens
Wound care
39
Q

Elevated ESR may mean

A

Anemia
Lupus
Rheumatoid arthritis
Bone infections

40
Q

ESR tests for

A

inflammation in the body

41
Q

Cranial nerve I

A

Olfactory (smell)

42
Q

Organs in LUQ

A 
Spleen
Stomach
Pancreas
Portion of left kidney 
Left adrenal gland
43
Q

Nursing process

A 
Assessment
Diagnosis
Planning
Implementation
Evaluation
44
Q

Stage 4 ulcer

A

Muscle, tissue and bone visible

45
Q

First cells to arrive at site where inflammation occur

A

Neutrophils

46
Q

Stage one ulcer

A

Skin red and unbroken

47
Q

Cranial nerve X (10)

A

Vagus ( talking, swallowing, carotid reflex)

48
Q

Stage 2 ulcer

A

Skin with epidermal and dermal injury

49
Q

Glasgow coma scale

A

Used to describe LOC following traumatic brain injury.
Measures eye opening, verbal and motor response
15 point scale

50
Q

Autonomy

A

Right of pt to receive adequate and accurate info to make a choice free from external constraints

51
Q

Cranial nerve V (5)

A

Trigeminal ( muscles of mastication, sensation of face and scalp)

52
Q

What is “mental status”

A

A persons emotional and cognitive functioning

53
Q

Breaking chain of infection for Portal of exit

A 
Handwashing
Waste disposal
Secretions/drainage
Protect open wounds
Gloves/masks
Medication
54
Q

Cranial nerve III (3)

A

Occulomotor (PERRLA, raise eyelids, pupil constriction, lens shape)

55
Q

Contact precautions

A

Most frequent mode of transmission
Ex: Hep A, herpes, C.Diff
Gloves, gown, private room in addition to standard precautions

56
Q

Four components of wellness

A

Capacity to perform
Ability to adjust
Reports feeling of well being
Feeling that everything is together

57
Q

Sensory function

A

Pressure, pain and temp

58
Q

Diurinal cycle

A

Temperature is lower in the morning and higher in the late afternoon

59
Q

Anisocoria

A

Unequal pupil size. May be caused b aneurysm, brain tumor, increased ICP, infection of membranes around the brain ex meningitis, encephalitis

60
Q

Cranial nerve IV (4)

A

Trochlear (downward and inward movement of the eye)

61
Q

General survey

A

Physical appearance
Body structure
Mobility
Behavior

62
Q

Rovsing’s sign

A

Pain in RLQ during pressure in LLQ. Sign of appendicitis, or peritoneal irritation

63
Q

Cranial nerve XI (11)

A

Spinal (controls muscles in the head/neck/shoulders)

64
Q

Nonmaleficence

A

Duty to not inflict harm

65
Q

Blumberg’s sign

A

Abdominal wall is compressed slowly and then rapidly released. Indicative of peritonitis

66
Q

Maslows Hierarchy of needs

A 
Self actualization
Esteem and self respect
Belongingness and affection
Safety and security
Basic needs
67
Q

Objective data in Behavior

A

LOC
Facial expression
Speech
Mood and affect

68
Q

Chain of infection

A 
Infectious agent
Resevoir
Portal of exit
mode of transmission
Portal of entry
Susceptible hose
69
Q

Breaking chain of infection for susceptible host

A 
Handwashing
rest
skin care
nutrition/fluids
Immunization
70
Q

Functions of skin

A 
Prevent loss of water and electrolytes
Regulate body heat
Produce vitamin D
Wound repair 
Excretion
71
Q

Psoas sign

A

Right hand above right knee, raise leg against resistance, flexion of hip causes contraction of psoas muscle. appendicitis?

72
Q

Pectus excavatum

A

Funnel chest

73
Q

Pectus carinatum

A

pigeon chest

74
Q

Rust/dark red sputum

A

TB, pneumonia, pnemococcal

75
Q

Yellow/green sputum

A

lung infection

76
Q

Hemoptysis

A

URI

bronchitis

77
Q

Genum varum

78
Q

Genum valgum

A

knock knees

Fundamentals of Nursing (12 decks)

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