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Nursing 202 > Exam 1 > Flashcards

Exam 1 Flashcards

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1
Q

What is undernutrition? Overnutrition?

A

-20% above or below the optimal nutritional level

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2
Q

What is morbid obesity?

A
  • 100% above the optimal body weight

- criteria for bariatric surgery

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3
Q

What is another name for overnutrition?

A

-obesity

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4
Q

What is overnutrition considered?

A

-malnutrition

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5
Q

What is Marasmus?

A
  • wasting syndrome

- inadequate intake of protein and calories

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6
Q

What are examples of Marasmus?

A
  • starvation
  • anorexia
  • bowel obstruction
  • cancer cachexia
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7
Q

What are the keys of Marasmus?

A
  • loss of subcutaneous fat
  • effects on every organ system
  • no edema
  • decrease of anthropometric measures and weight
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8
Q

What is Kwashiorkor?

A

-eating enough calories but not enough protein

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9
Q

What are the keys of Kwashiorkor?

A
  • edema
  • appear in normal range of anthropometric measurements
  • may even appear on the overweight side
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10
Q

What is Marasmus-Kwashiorkor mix?

A

-prolonged inadequate intake of calories and protein

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11
Q

What are the keys of Marasmus-Kwashiorkor mix?

A
  • muscle wasting
  • visceral muscle and fat loss
  • immune incompetence
  • high morbidity and mortality rate
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12
Q

When is Marasmus-Kwashiorkor seen?

A
  • severe burn patients
  • extensive surgery patients
  • prolonged starvation patients
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13
Q

What are the ways of Nutrition Screening?

A
  • 24-hour diet recall
  • food frequency questionnaire
  • food diaries- recorded every calorie for 2-3 weeks
  • direct observation
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14
Q

Who is the Food Guide Pyramid not applied to?

A

-sick people

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15
Q

What are some examples of subjective data in a health history?

A
  • eating patterns
  • usual weight
  • change in appetite
  • recent trauma
  • chronic illness
  • vomiting, nausea, diarrhea
  • allergies
  • medications or supplements
  • self-care behaviors
  • alcohol or drug use
  • exercise patterns
  • family history
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16
Q

What are some examples of objective data in a health history?

A
  • anthropometric measures: height, weight (ideal, current)
  • skin fold thickness (3x and take the average)
  • MAC (mid-upper arm circumference): muscle mass to fat storage
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17
Q

Why is a 2-1 waist to hip ratio dangerous?

A

-it can lead to diabetes, cardiac death, and other obesity-related diseases

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18
Q

What are some of the Laboratory Studies?

A
  • hemoglobin
  • hematocrit
  • iron deficiency
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19
Q

What do you use in an inspection? Keys?

A
  • all of your senses
  • unhurried
  • good lighting
  • from head to toe
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20
Q

What are the different inspection techniques?

A
  • palpation
  • percussion
  • auscultation
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21
Q

When is palpation used?

A

-to examine parts of the body under the skin

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22
Q

How deep is light palpation and when is it used?

A
  • up to 1cm deep
  • superficial rash
  • visible lump
  • pulse
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23
Q

How deep is deep palpation and when is it used?

A
  • 2-4 cm; deeper if patient has more subcutaneous adipose tissue
  • organs, distension, abdominal tenderness
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24
Q

When is palpation with the back of the hand used?

A

-when feeling for temperature

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25
Q

When is palpation with the sides of the hands used?

A

-when feeling for vibration

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26
Q

When is percussion used?

A

-when listening to the vibration of the stationary hand after the striking hand has hit it

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27
Q

What are the different sounds of percussion notes?

A
  • resonant
  • hyperresonant
  • tympany
  • dull
  • flat
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28
Q

What does resonant sound like and when is it normal?

A
  • clear, hollow, low pitched

- adult lung tissue

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29
Q

What does hyperreasonant sound like and when is it normal?

A
  • louder, hollow, low pitched

- child lung tissue (excess of air)

30
Q

What does tympany sound like and when is it normal?

A
  • loud, high pitched, drumlike
  • abdomen
  • hollow organs
31
Q

What does flat sound like and when is it normal?

A
  • soft, high pitched

- muscle, bone, tumor

32
Q

What does dull sound like and when is it normal?

A
  • muffled, thud

- dense organs like the liver and spleen

33
Q

What is auscultation?

A

-using a stethoscope to examine a patient

34
Q

What sound does the diaphragm listen for and what does it listen to?

A
  • high pitch sounds
  • breathing
  • bowel
  • normal heart sounds
35
Q

What sound does the bell listen for and what does it listen to?

A
  • low pitch sounds

- extra heart sounds

36
Q

What should not happen when listening with a stethoscope?

A
  • no rubbing
  • no clothes in the way
  • no shivering
37
Q

What are some behaviors that can be changes because of mental status?
CLMOAMATTP

A
  • consciousness
  • language
  • mood
  • orientation
  • attention
  • memory
  • abstract reasoning
  • thought process
  • thought content
  • perception
38
Q

When do you need to perform a full mental status examination?

A
  • behavioral change
  • brain lesions
  • aphasia
  • symptoms of psychiatric mental illness
39
Q

What objective data does a nurse record when examining for mental health status?

A
  • posture
  • body movements
  • dress
  • grooming and hygiene
  • level of consciousness
  • facial expression
  • speech
  • mood and affect
40
Q

What are the levels of consciousness?

A
  • alert
  • lethargic
  • obtunded
  • stupor or semi-coma
  • coma
  • delirium or acute confusional state
41
Q

What does someone who is alert look like?

A
  • awakens easily
  • aware of environment
  • responds to stimulus
42
Q

What does someone who is lethargic look like?

A
  • drifts off to sleep when not stimulated

- responds slowly to name

43
Q

What does someone who is obtunded look like?

A
  • physical contact needed
  • sleeps most of the time
  • difficult to arouse
  • remains sleepy
  • speech can be mumbled
44
Q

What does someone who is semi-coma look like?

A

-responds only to contact and appropriate response to pain only

45
Q

What are some cognitive functions that a nurse might directly observe when evaluating a patients mental health status?

A
  • orientation
  • attention span
  • recent memory
  • remote memory
  • new learning/ four unrelated word test
  • judgment
46
Q

What are some thought processes and perceptions that a nurse might directly observe when evaluating a patients mental health status?

A
  • thought processes
  • thought content
  • thought perceptions
  • screening for suicidal thoughts
47
Q

What are the different lymph nodes of the head and neck?

A
  • preauricular
  • posterior auricular
  • occipital
  • submental
  • submandibular
  • jugulodigastric
  • superficial cervical
  • deep cervical
  • posterior cervical
  • supraclavicular
48
Q

When are lymph nodes the most palpable?

A

-when they are enlarged

49
Q

What does it mean most often when lymph nodes are soft and tender?

A

-infections

50
Q

What does it mean most often when lymph nodes are hard and fixed?

A

-leaning towards cancer

51
Q

What are some examples of subjective data when relating to the head and neck region?

A
  • headache
  • head injury
  • dizziness
  • neck pain, ROM limitation
  • lumps or swelling
  • history of head or neck surgery
52
Q

What are some questions to ask relating to head or neck pain?

A
  • when did it start
  • how sudden
  • how painful
  • was there an injury
  • what happened after that injury
53
Q

Where are some places to inspect related to the head and neck area?

A

-insect and palpate the size and shape of the skull
-focus on temporal area
inspect the facial structures for abnormalities, lesions, and tics
-inspect and palpate the symmetry, ROM, lymph nodes, trachea, thyroid gland of the neck

54
Q

What are some characteristics of a normal trachea? three m

A
  • midline
  • move up with swallowing
  • mobile
55
Q

What are some abnormal findings related to the head and neck region?

A
  • parkinsons
  • cushings syndrome
  • hyperthyroidism
  • hypothyroidism
  • bells palsy
  • cerebrovascular accident
  • cachectic appearance
  • scleroderma
56
Q

What are the symptoms of cushings syndrome?

A
  • moonlike appearance

- red cheeks

57
Q

What are the symptoms of hyperthyroidism?

A
  • goiter
  • bulging eyes
  • nervous
  • fatigue
  • weight loss
58
Q

What are the symptoms of hypothyroidism?

A
  • aka myxedema
  • edema around the eyes
  • dry skin
  • course hair
59
Q

What are the symptoms of cachectic appearance?

A
  • dehydration
  • skinny
  • sunken eyes
60
Q

What are the symptoms of scleroderma?

A

-hardened skin

61
Q

What is the purpose of taking a health history?

A
  • to collect, document, and analyze

- helps determine scope of practice

62
Q

What are the expanding assessment factors?

A
  • growth and development
  • biophysical status
  • emotional status
  • cultural and religious background
  • performance of ADLs
  • patterns of coping
63
Q

What are the four types of data to collect?

A
  • complete health history
  • problem-centered data base (only addressing the problem you come in for)
  • follow up data base
  • emergency data base (getting as much info as possible while addressing vitals and critical areas)
64
Q

What are the two frequencies of assessments?

A
  • annual checkups

- age-specific charts for periodic health examination (focuses on major risk factors specific for each age group)

65
Q

What are four things to get in the health history?

A
  • biographical data
  • source of history
  • reason for seeking care
  • present health or history of present illness
66
Q

What are the critical characteristics of a symptom?

PQRSTU

A
  • provocative or palliative
  • quality or quantity
  • region or radiation
  • severity scale
  • timing
  • understand patients perception
67
Q

What are the different body areas to review?

A
  • overall
  • skin
  • hair
  • head
  • eyes
  • ears
  • nose and sinuses
  • mouth and throat
  • neck
  • breast axilla
68
Q

What are the different body systems to review?

A
  • cardiovascular
  • peripheral vascular
  • gastrointestinal
  • urinary system
  • genital system
  • sexual health
  • musculoskeletal
  • neurologic
  • hematologic
  • endocrine
69
Q

What are some factors of functional assessment?

SASNSIC

A
  • self-esteem, self-concept
  • activity, exercise
  • sleep, rest
  • nutrition, elimination
  • spiritual resources
  • interpersonal relationships, resources
  • coping and stress management
70
Q

What are the personal and social history factors of functional assessment?

A
  • personal habits
  • alcohol
  • street drugs
  • environment, hazards
  • intimate partner violence
  • occupational health
  • perception of health

Nursing 202 (4 decks)

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