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Exam 1-Skills Flashcards

1
Q

Subjective Data

A

symptoms/ what patient is feeling

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2
Q

Objective Data

A

Nurse gathers/can see

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3
Q

A Patient is what source of data?

A

Primary source

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4
Q

Support People (family/ friends) is what source of data?

A

Secondary source

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5
Q

Other healthcare professionals are what source of data?

A

Secondary source

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6
Q

Observation is using what data collection method?

A

Senses

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7
Q

What are the 4 types of nursing assessment and what are examples of each?

A
  1. Initial
    (general doc visit)
  2. Focused-
    (focused on problem)
  3. Emergency-
    (wound treated 1st)
  4. Time lapsed-
    (issue happened months ago)
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8
Q

Ways problems can occur r/t data collection?

A

-co worker forgets to tell you
-duplicated data
-misinterpreted data
-no trust
-recording as data rather than observed behavior

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9
Q

Validating

A

double checking/ verifying

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10
Q

Inspection

A

purposeful observation

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11
Q

Palpation

A

the act of using the sense of touch

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12
Q

Percussion

A

the act of striking one object against another to produce a sound

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13
Q

Auscultation

A

the act of listening with a stethoscope to sounds within the body

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14
Q

When assessing the skin assess for:

A

-color
-moisture
-temperature
-texture
-turgor
-vascularity
-Edema/swelling
-Lesions

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15
Q

Pallor

A

reduction in tissue breakdown

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16
Q

Turgor

A

elasticity/measure of hydration

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17
Q

Pitting edema leaves indentation:

A

+1 = 2mm
+2 = 4mm
+3 = 6mm
+4 = 8mm

round up if in between

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18
Q

Inspect lesions for:

A

-color
-location
-texture
-size
-shape
-distribution
-exudate/drainage

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19
Q

When assessing hair inspect for:

A

-even distribution
-thickness
-texture

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20
Q

When assessing nails inspect for:

A

-nail bed color (pink)
-tissue around nails (intact)
-angle between nail and nail bed (160*)
-Texture
-capillary refill (<3 sec.)

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21
Q

Inspect skull for:

A

-size
-shape
-symmetry
-Nodules
-Masses
-lesions

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22
Q

Inspect nose for:

A

-position
-symmetry
-nasal flaring

Palpate for:
-Pain
-tenderness
-swelling

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23
Q

Inspect frontal & maxillary sinuses for:

A

-periorbital edema
-dark circles under eyes

Palpate with thumbs for:
Tenderness

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24
Q

Angioedema

A

a dermal, subcutaneous or submucosal swelling that is acute, painless and of short duration

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25
Conjunctiva
Normal: -shiny -smooth -pink/light red Abnormal: -extremely pale -extremely red
26
Normal Pupil
-black -equal 3-7mm in diameter
27
PERRLA
Pupils equally round and react to light and accommodation *determines function of 3rd (oculomotor) & 4th (troclear) cranial nerves
28
Cataracts
-Opacity or clouding of lens -blurry vision -glare when driving -double vision
29
Glaucoma
-increased intraocular pressure -loss of peripheral vision -halo's around lights
30
20/40
20 top number is the distance from the chart; ALWAYS THE SAME bottom number is the distance from which the normal eye can read the chart
31
Normal tympanic membrane
-shiny -pearly gray -intact
32
Cerumen
ear wax
33
Conductive hearing loss
-tear in the tympanic membrane -obstruction -swelling in the auditory canal
34
Sensorineural hearing loss
-damage to the inner ear -damage to the auditory nerve -damage to the hearing center in the brain
35
Weber Assessment
Evaluates bone conduction + = sound heard better in one ear - = sound heard equally in both ears
36
Rinne Assessment
Compares air conduction with bone conduction *patient should hear the air conducted tone for twice as long as the bone conducted tone + = AC>BC - = BC >AC or BC = AC
37
Motor Function
-Muscle size -tone -strength -movement
38
Cerebellar Function
-balance -coordination
39
Gait
-walk
40
Grading Muscle strength
5/5= 100% Normal 4/5= 75% Good 3/5= 50% Fair 2/5= 25% Poor 1/5= 10% Trace 0/5= 0% Zero
41
Common Blood-borne Pathogens
Hepatitis B&C HIV
42
Antiseptic Hand Rub
reduce # of microorganisms present
43
Alcohol based hand rub
decreases viable organisms
44
Antimicrobial soap
decrease # of microbial flora
45
Use soap and water when....
visibly soiled, before you eat and go home
46
Standard Precautions
-guidelines recommend by the CDC -used in the care of all patients regaurdless of their diagnosis Use when: -blood -bodily fluids -non intact skin -mucous membranes
47
Order of PPE on:
-gown -mask -eye protection -gloves
48
Order of PPE off:
-gloves -eye protection -gown -mask
49
PAPR
Powered Air Purifying Respirator Used when: -N95 does not fit -facial hair
50
Airborne Precautions
Respiator
51
Droplet Precautions
Mask 3 ft of patient
52
Contact Precautions
Gown, gloves, facial protection when appropriate
53
Medical Asepsis
Clean technique
54
Surgical Asepsis
Sterile Technique
55
Medical Asepsis or Surgical Asepsis? Rectal Temperature
Medical
56
Medical Asepsis or Surgical Asepsis? Foley Insertion in hospital
Surgical
57
Medical Asepsis or Surgical Asepsis? Foley Insertion at Home
Medical
58
Medical Asepsis or Surgical Asepsis? IV Insertion
Sterile
59
Medical Asepsis or Surgical Asepsis? Dressings
Depends on dressings
60
Medical Asepsis or Surgical Asepsis? IM injections
Sterile
61
Medical Asepsis or Surgical Asepsis? NG insertions
medical (don't sterilize the food we eat)
62
What would you do if sterile technique has been broken?
Start over
63
Sterile Field
a area free of microorganisms
64
A person or animal that harbors a specific infectious agent and serves as a potential source of infection yet does not manifest any clinical signs of the disease is a ________.
-Carrier
65
Fomites
non living objects
66
Which precaution should be implemented when there are clients with wound infections?
Contact Precautions
67
Erythema
Redness
68
Ecchymosis/ ecchymotic
bruising
69
Hematoma
collection of blood
70
Exudate
Drainage
71
Serous
clear/watery
72
Sanguineous
blood/red
73
Serosanguineous
Pink
74
Purulent
Pus
75
Approximated
closed tissue surfaces
76
Dehiscence
splitting of wound
77
Evisceration
Splitting of wound and can see organs coming out
78
What to do if Dehiscence/evisceration happens?
-Sterile dressing soaked with saline -Steri strips -Call doctor
79
Slough
Yellow, narcrotic
80
Necrosis
black/dead
81
Wound Debridement
Removal of necrotic, non-viable tissue, pressure ulcers, burns and other wounds
82
4 Methods of Debridement
-Sharp or scalpel- surgical removal -Mechanical- scrubbing force/wet to dry -Chemical- enzymes & other compounds to dissolve necrotic tissue -Autolytic-transparent dressing-body is able to dissolve dead tissue
83
Granulation
red, bumpy tissue in the wound bed as the wound heals
84
Ischemia
reduced blood flow
85
Abrasion
a scrape
86
Laceration
a deep cut or tear in skin
87
Sepsis
the body responds improperly to an infection
88
Asepsis
the absence of bacteria, viruses, and other microorganisms.
89
Nosocomial Infection
infection(s) acquired during the process of receiving health care that was not present during the time of admission
90
Vehicle
occurs when a substance, such as soil, water, or air, carries an infectious agent to a new host.
91
Vector
mosquitoes and ticks
92
Olfactory
smell
93
Hypoglossal
nerve function is to control the muscles of the tongue
94
Vagus Nerve
one of 12 cranial nerves in the body. It's responsible for various bodily functions, including digestion, heart rate, and breathing
95
Trochlear Nerve
controls the superior oblique muscle in your eye
96
Accessory Nerve
essential for neck and shoulder movement
97
Myopia
nearsightedness
98
Astigmatism
front surface of the eye or the lens, inside the eye, is curved differently in one direction than the other Blurry vision
99
Normacephalic
a person whose head and all major organs of the head are in a normal condition and without significant abnormalities
100
Glossitis
inflammation of the tongue
101
Sims
lying on the left side, left hip and lower extremity straight, and right hip and knee bent.
102
Fowlers
The bed angle is between 45 degrees and 60 degrees sitting position
103
Lithotomy
a supine position of the body with the legs separated, flexed, and supported in raised stirrups, originally used for lithotomy and later also for childbirth.
104
Prone
person lies flat with the chest down and the back up
105

Nursing Fundamentals (12 decks)

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