exam 2 Flashcards
What is:
-The body’s general, nonspecific response to demands placed by the stressor
Stress
What is:
-How an individual deals with problems/issues
-Cognitive and behavioral
Coping
What is:
-An external influence that threatens to disrupt the equilibrium
Stressor
What type of stressor is:
-Directly trigger stress response without any cognitive process
Biogenic
What type of stressor is:
-Directly trigger stress response due to coping, anxiety, guilt, fear, frustration, loss
Psychological
What is:
-Behaviors used to decrease stress and anxiety
example: crying, exercise, drinking, smoking
Coping mechanisms
What is:
-A stress response characterized by feeling of mental uneasiness, apprehension, dread
Anxiety
What type of anxiety is:
-A general uneasiness and nervousness
Mild anxiety
What type of anxiety is:
-Disturbing feeling that something is wrong
Moderate anxiety
What type of anxiety is:
-Feeling of dread and horror
-Difficulty following directions
Severe anxiety
What type of reaction is:
-Inability to focus, terror, bizarre behavior
-Perception distorted
Panic disorder
What are the 9 factors that affect body temp?
-Age
-Sex
-Diurnal variation
-Exercise
-Stress
-Meals
-Drugs
-Smoking
-Site of measurement
What would be the diagnosis if a pt presented with these s/s?
-Flushing, hot
-Poor appetite, N/V/D
-Tachycardia
-Tachypnea
-Fatigue, malaise
-Weakness
-Lowered responsiveness
Hyperthermia
What are the 6 risk factors for hyperthermia?
-Age
-Obesity
-Medications
-Climate
-Immune compromised
-Infections
These s/s are a sign of what?
-Faint or dizzy
-excessive sweating
-cold, clammy skin
-Nausea/vomiting
-rapid, weak pulse
-Muscle cramps
Heat exhaustion
These s/s are a sign of what?
-Throbbing headache
-No sweating
-Body temp above 103
-Nausea/vomiting
-Rapid, strong pulse
-May lose consiousness
Heat stroke
These symptoms are a sign of what?
-Initial shivering
-Slow, shallow breathing
-Weak pulse
-Changes to mental status
-Pale, cool, waxy skin
Hypothermia
What are the 6 risk factors for hypothermia?
-Age
-Medications
-Climate
-Mental conditions
-trauma, burns
-Sepsis
These s/s are a sign of what?
-Cold skin/ prickling feeling
-Numbness
-Hard or waxy skin
-Clumsiness sue to joint and muscle stiffness
-Red, white, bluish-white or grayish-yellow skin
Frostbite
What wound classification is:
-Break in skin
Open
What wound classification is:
-Intact skin
Closed
What type of wound bed would be:
-tissue is pink
-no necrosis
Healthy
What type of wound bed would be
-Dark red
-often bleeds
-eschar or sloughing
Unhealthy
What stage in the healing process is: -Minimal tissue loss, skin edges are approximated
Example: closed surgical incision
Primary
What stage in the healing process is: Considerable tissue loss, skin edges are open, repair time longer
Example: pressure ulcer
Secondary
What stage in the healing process is: wound becomes infected and has reopened
Tertiary
What PU stage is:
-Non blanchable erythema
-Different temp than surrounding skin
Stage 1
What PU stage is:
-Partial-thickness skin loss
-May present as intact or open-serum filled blisters
Stage 2
What PU stage is:
-Full-thickness skin loss
-Deep crater w/o undermining or tunneling
Stage 3
What PU stage is:
-Full thickness skin loss with tissue necrosis and damage to underlying structures
-Muscle, ligament, or bone
-Tunneling
Stage 4
What type of PU is:
-Most serious
-Intact or non-intact
-persistent non-blanchable deep red, maroon or epidermal separation revealing a dark wound bed or blood-filled blister
deep tissue PU
What results from intense /or prolonged pressure and shear forces at the bone-muscle interface
deep tissue PU
On the Braden scale, the _______ the number, the ______ the risk for ulcer or injury
-lower
-higher
What occurs when:
-when loss of ECF volume exceeds the intake of fluid
Hypovolemia
These are causes of what?
-Abnormal fluid loss
-decreased fluid intake
-third-space fluid shift
Hypovolemia
What occurs when-
-An isotonic expansion of the ECF caused by the abnormal retention of water and sodium
Hypervolemia
What is:
-the invasion of a susceptible host by pathogens or microorganisms, resulting in disease
Infection
What stage of the infectious process is:
-Interval between entrance of pathogen into body and appearance of first symptoms
Incubation period
What stage of the infectious process is:
-interval from onset of nonspecific s&s to more specific symptoms
Prodromal stage
What stage of the infectious process is: interval when pt manifests s&s specific to type of infection
Illness stage
What stage of the infectious process is: interval when acute symptoms of infection disappear
Convalescence
What type of the body’s defense is: immediate response of the body to invasion
Inflammatory response
What:
-contain DNA or RNA but con not replicate by itself
-Reproduce itself outside the host cell
-mutate rapidly
Viruses
What is:
-characterized by inflammation of mucous membranes, fever, cough, headache, malaise
-Sudden onset, clear lung sounds
influenza
What is:
-contaminated air inhaled and passed into alveoli
-accumulation of cells in the alveolar space
Pneumonia
What are the 4 types of pneumonia?
-Community-acquired
-Hospital acquired
-Ventilator-associated
-Aspiration
Urethritis and cystitis are what type of UTI’s
Lower UTI’s
-Acute pyelonephritis
-interstitial nephritis
-renal nephritis
are what type of UTI’s
Upper UTI’s
these s/s are of what?
-dysuria
-urethral discharge
urethritis
these s/s are of what?
-sudden onset
-polyuria, anuria
-nocturia
-urine is turbid
-possible low grade fever
cystitis
What is:
-a response triggered by the body in response to injury, insult, or infection
Inflammation
what type of inflammation is a good thing
acute
Where is Mcburney’s point located
RLQ
Where is rovsing’s sign located
LLQ
Pt presents with s/s of:
-Flushed skin
-restlessness
-Increased BP
-edema
-decreased urine
-skin is dry
-agitation
-low grade fever
-thirst
would be indicative of what?
Hypernatremia
These causes would lead to what?
-Burns
-fluid loss
-diabetes’s insipidus
Hypernatremia
Pt presents with s/s of:
-stupor/coma
-lethargy
-tachycardia
-limp muscles/muscle twitching
-orthostatic hypotension
-seizures
what be indicative of what?
Hyponatremia
These causes would lead to what? 5 D’s
-diaphoresis
-diarrhea/vomiting
-drains (NG)
-diuretics
-dilution
Hyponatremia
FRIEDSALT is the pneumonic for?
Hypernatremia
SALTLOSS is the pneumonic for?
Hyponatremia
pt presents with s/s of:
-Muscle cramps
-urine abnormalities
-respiratory distress
-bradycardia & hypotension
-EKG changes
-low DTR
Can be indicative of what?
Hyperkalemia
- cellular movement (Burns, tissue damage)
-Adrenal insufficiency
-renal failure
-drugs (ACE inhibitors, NSAIDS)
would cause what?
Hyperkalemia
What causes peaked T-waves
Hyperkalemia
pt presents with s/s of: 6 L’s
-lethargy
-leg cramps
-limp muscles
-low respirations
-lethal dysrhythmias
-lots of peeing
-low BP
Hypokalemia
What causes flattened T-waves
Hypokalemia
-drugs (loop diuretics, laxatives)
-inadequate consumption
-too much water intake
-heavy fluid loss
can cause what?
Hypokalemia
MURDER is the pneumonic for?
Hyperkalemia
Muscles contract for TOO long with?
Hyperkalemia
Muscles contract LESS with?
Hypokalemia
pt presents with s/s of:
-Bone pain
-arrythmias
-cardiac arrest
-muscle weakness
-polyuria
would be indicative of what?
Hypercalcemia
-Hyperthyroidism
-Excessive intake of antacids & Vit. D
-Kidney disease
would cause what?
Hypercalcemia
BACKME is a pneumonic for?
Hypercalcemia
pt presents with s/s of:
-convulsions
-arrythmias
-tetany
-spasms
-numbness in fingers, face, limbs
would be indicative of what?
Hypocalcemia
Positive trausseau’s and chvosteks signs are indicative of what?
Hypocalcemia
3 D’s
-Diuretics
-Diarrhea
-Drainage from wounds
are the causes for?
Hypocalcemia
Nervous system is hyperactive in-
Hypocalcemia
pt presents with s/s of:
-hypotension
-Decreased DTR
-greatly decreased respiratory rate
-hyperreflexia
would be indicative of what?
Hypermagnesemia
-excessive intake of TUMS
-advanced renal failure
-DKA
are causes of what?
Hypermagnesemia
in hypermagnesemia, everything is -
LOW
pt presents with s/s of:
-tremors
-weakness
-tachycardia
-Irrability
-tetany (muscle spasms)
-confusion
-hyperactive reflexes (increased DTR)
would be indicative of what?
Hypomagnesemia
-GI loss
V/D/NG suction
-Chronic alcoholism
are the causes of what?
hypomagnesemia
In hypomagnesemia, everything is-
HIGH
what are the 5 signs of inflammation?
-pain
-heat
-redness
-swelling
-loss of function
-analgesics
-cough medicines
-antivirals
-symptomatic meds
is the treatment for what?
influenza
What illness are these risk factors for?
-children 2 years old or younger
-65 years and older
-hospitalization
-COPD
-smoking
-suppressed immune system
pneumonia
These treatments are for what illness?
-antibiotic therapy
-bronchodilators
-oxygen therapy
-prevention
pneumonia
these nursing interventions are used for what?
-remove every 2 hours
-monitor neuro and sensory status every 2 hours
-providers need to renew every 24hrs
Restraints
Adaptive or maladaptive coping?
Seeking therapy or treatment
Adaptive
Adaptive or maladaptive coping?
-drinking, feeling sad/withdrawn, not applying for a job because of fear
maladaptive
these nonpharmacological treatments are to treat what?
-stay in bed and rest
-drink plenty of fluids
-stay cool (remove clothing/blankets)
-take tepid baths
fever
These OTC meds are used to treat what?
-Acetaminophen
-NSAID (Advil or Motrin)
fever
What would these treatments help?
-rewarming of skin
-oral pain meds
-loosely wrap injury with sterile towels/dressings to protect skin
-NEVER massage area
hyperbaric O2 therapy
Hypothermia
These nursing interventions are for what?
-cool compresses
-fluid intake
-monitor VS/ administer antipyretics
Heat exhaustion
These nursing interventions are for?
-immerse pt in cold water
-pack pt with ice/cooling blankets
-cold fluid IV
Heat stroke
