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NUR 225 > Exam 1 > Flashcards

Exam 1 Flashcards

1
Q

What are the levels of consciousness

A

Alert
Lethargic
Obtunded
Semi comatose
Comatose

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2
Q

Alert

A

Receptive and responsive

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3
Q

Lethargic

A

Responds appropriately but is slow and may need stimuli to remain awake

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4
Q

Obtunded

A

Difficult to arouse, requires constant stimulation to stay awake and inconsistently follows commands

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5
Q

Semicomatose

A

Requires extreme or repeated stimuli but responds with purposeful movement, does not follow commands, nonverbal

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6
Q

Comatose

A

Unconscious with no meaning response to stimuli

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7
Q

PERRLA

A

Pupils equal round react to light and accommodate- coverage and constrict

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8
Q

Miosis

A

<3mm

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9
Q

Mydriasis

A

> 7mm

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10
Q

Anisocoria

A

unequal

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11
Q

Diplopia

A

Double vision

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12
Q

Pinpointed pupils

A

Narcotics

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13
Q

Dilated pupils

A

Scopolamine patch
Amphetamines
Cough medicine
Cocaine
LSD

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14
Q

What are the components of EMV

A

Eye opening
Motor response
Verbal response

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15
Q

Eye opening response

A

4 spontaneously
3 to speech
2 to pain
1 no response

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16
Q

Verbal response

A

5 oriented to time, person, and place
4 confused
3 inappropriate words
2 incomprehensible sounds
1 no response

17
Q

Motor response

A

6 obeys commands
5 moves to localized pain
4 flex to withdrawal from pain
3 abnormal flexion
2 abnormal extension
1 no response

18
Q

Decorticate

A

Problems with cervical spinal tract or cerebral hemisphere

19
Q

Decerebrate

A

Problems with midbrain or pons

20
Q

Is decorticate or decerebrate worse

A

Decerebrate is technically worse because it signifies a more profound neurological insult affecting a lower brainstem level

21
Q

What is the accommodation test

A

Use pen light and bring to patients nose ensuring that their pupils converge and constrict

22
Q

Sensory overload

A

Reception of multiple sensory stimuli
Pain, lack of sleep, worry, frequent treatments, decreased cognitive ability, irritability, anxiety, restlessness, disorientation, and more.
Nurses should work to modify the environment to the patients liking, control pain, orientation cues, schedule routine of care and prepare client for procedures, and more.

23
Q

Sensory Deprivation

A

Inadequate quality or quantity of simulation
Private rooms or confinement, isolation, loss of senses, restrictions, emotional withdrawal, drowsiness, impairment memory, disorientation.
Nurse should provide multi sensory stimuli, frequent meaningful interactions, reorient frequently, social stimulation, and more.

24
Q

Presbyopia

A

Unable to see near objects

25
Q

Cataracts

A

Clouding of lens

26
Q

Glaucoma

A

Increase intraocular pressure

27
Q

Macular degeneration

A

Portion of the retina loses function

28
Q

Diabetic retinopathy

A

Pathological changes in the blood vessels

29
Q

How to care for patients with visual impairments

A

Announce presence
Stay in their field of vision
Explain what you are doing
Keep pathways clear
Assist with ambulation

30
Q

Presbycusis

A

Hearing loss due to aging

31
Q

Hearing loss r/t loud noises

A

Working in a factory
Noise induced hearing loss

32
Q

Hearing loss r/t tissue damage

A

Secondary to repeated infections or ototoxic medications-mycins, furosemide

33
Q

interventions for auditory deficits

A

Cheating for impacted cerumen
Amplification of sounds or flashing lights for safety
Slower speech and tones
Communication boards
Short sentences

34
Q

What are red flag symptoms of a headache

A

Fever
Weight loss
Altered mental status
Weakness
Papilledema
Proximal artery tenderness
Severe headache triggered by intercourse, cough, or exertion

35
Q

Tension headache

A

Usually associated with a stressful event/ muscular contraction in the neck and scalp
Pressing or tightening pain
Occipitofrontal location; bilateral pain
Mild to moderate intensity
Lack of effect of physical activity
Nurse should give necessary medications, encourage rest, massages, etc.

36
Q

Cluster headache

A

Severe and unilateral
Sharp unilateral orbital, supraorbital, or temporal pain accompanied by autonomic symptoms on the affected side.
Patient becomes restless
Episodes can last 15-180 minutes and occur in increments
Nurses should utilize supportive care and pain medication

37
Q

Migraine

A

Severe disabling, unilateral headaches
Described as pulsating
Sensitivity to light, sound, and smells, nausea, stiff neck
Nursing care includes modifying the environment, start IV, and manage the symptoms

NUR 225 (3 decks)

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