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► Nursing Notes > Exam 1: NR 414 > Flashcards

Exam 1: NR 414 Flashcards

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1
Q

What are the 4 components of Diagnostics

A
  1. cues,
  2. info,
  3. signs,
  4. symptoms,
  5. lab data
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2
Q

Diagnosis

A

Valid influences, compare “clusters”, identify related factors

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3
Q

What are some components of Critical Thinking

A

identify assumptions, validate, normal/abnormal, relevance, inconsistencies, patterns, missing info, actual & potential risk, setting priorities, patient centered, evaluate

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4
Q

4 Types of Data

A
  1. Complete Health Data
  2. Episodic/Problem Centered/Focus data
  3. Follow-up data
  4. Emergency data base (ABCs)
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5
Q

3 Phases of Interview

A

1) Process of Communication 2) Internal 3) External Factors

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6
Q

Process of Communication means.

A

sending/receiving internal/external facotrs

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7
Q

Techniques of Communication x6

A
  1. open vs closed ended questions
  2. nonverbal skills,
  3. eye contact,
  4. voice,
  5. touch,
  6. dress
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8
Q

What are ways we overcome communication barriers

A

interpreters, vocal cues, action cues, object cues, space/touch

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9
Q

What are 2 types of measuring mental disorders

A

organic & psychiatric

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10
Q

Alert & Oriented x 4 (behavior orientation)

A

1) person 2) place 3) time 4)situation (what brought you here)

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11
Q

What are 4 components of mental health assessment

A

1) appearance 2) behavior 3) cognition 4) thought processes

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12
Q

QPR stands for

A

question, persuade, refer

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13
Q

Broca refers to

A

physical incapability to speak

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14
Q

Wernicke

A

not being able to speak correctly

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15
Q

What is ethnicity

A

a group having similar traits: common language, common heritage and cultural similarities

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16
Q

Race

A

relates more towards the appearance of a person. Biologically with inherited genetic traits.

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17
Q

Heritage

A

ancestors of a person

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18
Q

What is a database?

A

Sub & Objective data gathered from a patient plus the results of any diagnostic studies completed

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19
Q

What does PQRSTU Stand for

A

1) Provocative 2)Quality/Quantity 3)Region/Radiation 4) Severity 5) Timing 6)Understanding

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20
Q

How would you describe the pitch of a sound wave obtained by a percussion

A

number of vibrations per second

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21
Q

Which aperture is used for a patient with undilated pupils

A

small

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22
Q

During gen survey what are the 4 areas of interest

A

1)Appearance 2)Body structure 3)Mobility 4)Behavior

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23
Q

A normal pulse for a patient is..

A

2+

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24
Q

What is pulse pressure

A

the difference between systolic and diastolic pressure

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25
Q

What is the mean arterial pressure

A

diastolic pressure plus one third pulse pressure

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26
Q

what is nociception

A

pain receptors

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27
Q

neuropathic pain

A

burning painful sensation that moves around toes and bottoms of feet.

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28
Q

Complex Regional Pain I

A

chronic pain that usually affects an arm or a leg.

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29
Q

P-OLDCARTS

A

previous hx, onset, location, duration, character, aggravating, radiation, timing, severity

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30
Q

What are the 4 steps in a regular physical exam

A

1) inspection 2)Palpation 3)Percussion 4)Auscultation

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31
Q

What is normal temp in axillary

A

97.6F or 38.4C

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32
Q

What is normal temp in tympanic membrane?

A

98.6F

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33
Q

What is the conversion Celsius to Fahrenheit

A

C= 5/9 (f-32)

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34
Q

What is the conversion for Fahrenheit to Celsius

A

(9/5 x C) +32

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35
Q

What does a doppler do?

A

picks up changes in sound frequency as blood flows

36
Q

When is mobility decreased

A

with edema

37
Q

What does sterile mean?

A
  • no life
  • using special gases
  • high heat
38
Q

When is surgical apses necessary?

A
  • intentional perforation of the skin
  • body cavity, not exposed to outside
39
Q

What are the golden rules of surgical apses

A
  • an object below the waist is contaminated, because it is out of range of vision
  • never turn your back on a sterile field
  • keep trashcan close by, or drop on ground
  • Both patient and provider wear mask
  • If you break sterile technique- START OVER
  • 1” border
40
Q

Name 5 types where patient needs surgical asepsis technique

A
  1. Open Body Cavity
  2. Catheter
  3. Burns
  4. Central Line
41
Q

What are 6 maor things you want to palpate for in skin hair nails

A
  1. Temperature
  2. texture- use finger tips
  3. moisture
  4. diaphoresis (sweating)
  5. thickness
  6. Edema
42
Q

How is edema measured?

A
  • 4 point scale
  • 1+ = 2mm
  • 2+ = 4mm……
43
Q

3 Common types of birthmarks

A
  1. freckles
  2. junctional nevus
  3. compound nevus
44
Q
A

junctional nevus

45
Q
A

Compound Nevus

46
Q

What are the abnormal signs for pigmented lesions

A

ABCDE

47
Q

ABCDE stands for

A
  • Asymmetry
  • Border
  • Color variation
  • Diameter grater than 6mm
  • Elevation or Enlargement
48
Q
A
  • Confluent Lesion
  • ex hives//uriticaria
49
Q
A
  • Discrete lesion
  • Skin tags//acne
50
Q
A

Gyrate Lesion

51
Q
A
  • zosteriform
  • linear around unilateral nerve
  • ex: herpes
52
Q
A
  • Polycyclic
  • i.e. psoriasis
  • anular lesions grow together
53
Q

What are primary skin lesions x6

A
  • Macular/Patch
  • Papule/Plaque
  • Nodule/Tumor
  • Vesicle/bulla
  • Cyst
  • Postule
54
Q
A
  • Macule
    • Patch larger than 1 cm
  • flat not raised
55
Q
A
  • Papule
    • Plaque larger than 1 cm
  • can feel, slightly elevated
  • mole wart
56
Q
A
  • Nodule
    • tumor larger than 3 cm
57
Q
A
  • Wheal
    • Urticaria-hives
  • raised irregular shape due to edema
  • mosquito bites, allergies
58
Q
A
  • Vesicle
    • Bulla- larger than 1cm
  • a blister, herpes chicken pox, shingles
59
Q

What are some secondary Skin lesions?

A
  • Crust
  • Scale
  • fissure
  • erosion
  • ulcer
  • Excoriation
  • scar
  • atrophic scar
  • lichenfication
  • Keloid
60
Q
A
  • Scale
  • compact flakes of skin
61
Q
A
  • Keloid
    • hypertrophic scar
    • elevetated skin by excess scar tisue
62
Q
A
  • Pressure Ulcer Stage I
  • red but ubroken
  • will not blanch
63
Q
A
  • Stage 3 ulcer
  • extending into subcutaneous tissue
  • resembling a crater
64
Q
A
  • Stage IV Ulcer
  • breaks through all skin layers
  • visible bone or tendons
65
Q

What are some vascular lesions

A
  • petechiae
  • purpura
  • hematoma
  • contusion
66
Q

Epidermis layer

A
  • basal layer,
  • thin,
  • stratum corneum
67
Q

Dermis Layer

A
  • collagen
  • elastic tissue
68
Q

Subcutaneous layer

A
  • adipose tissue
69
Q

When irrigating a wound, how would the nurse know the right amount of pressure to apply?

A

between 5 and 15psi

70
Q

Which device is used for wound irrigation?

A

19 gauge needle attached to 35 mL syringe

71
Q

Elsevier:

What is the nursing action to set up suction for a hemovac drainage system?

A

the nurse should compress it firmly and replace the plug.

72
Q

Elsevier:

Which imaging study or diagnostic test would the nurse review to determine if the pressure ulcer on a patient’s left heel is infected?

A

Culture & sensitivity

73
Q

Elsevier:

What is the proper method for cleansing the evacuation port of a wound drainage system?

A

Wipe it with an alcohol sponge.

74
Q

Braden Scale

A

Risk for skin breakdown/Pressure ulcer

75
Q

What is the primary intention for wound healing?

A
  • tissue surfaces have been approximated
  • low tissue loss
  • remove dressings after drainage
76
Q

What is secondary intention for wound healing?

A
  • considerable tissue loss
  • edges cannot be drawn together
  • longer to heal
  • scarring is greater
  • infection risk
    • Pressure ulcers
  • continue dressings for moisture
  • assist debridement
77
Q

What are the phases for a full thickness wound repair?

A
  1. Hemostasis (fibrin)
  2. Inflammatory phase
  3. Proliferative phase- epithelial
  4. Remodeling- can take years
78
Q

What is required in the delivery of culturally congruent care?

A
  • knowledge
  • skills
  • attitudes
79
Q

What is an example of a nurse stereotyping a patient?

A

do you bathe and use deodorant more than one time a week?

80
Q

What are appropriate questions to ask a native american?

A
  1. do you use folk remedies
  2. do you have a family physician
  3. do you use a shaman
81
Q

What is an example of data validation

A
  • comparing values with previous values
  • report to charge nurse
82
Q

What are the steps for a nursing diagnosis?

A
  1. review assessment data
  2. cluster
  3. diagnostic label
  4. contet of pt’s health probl and select related factor
83
Q

What could be indicated when a reddened area blances on fingertip touch?

A

blanching hyperemia. Body overcoming ischemic episode

84
Q

To determine wound infection, where should the specimen be taken?

A

wound, after it has been cleaned with normal saline

85
Q

After surgery a patient coughs and opens up a wound. What is the nurse’s first intervention?

A

cover with saline-soaked towels and notify surgical team.

Evisceration

► Nursing Notes (33 decks)

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