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Fundamentals of Nursing II > Exam 2 Ch. 14, 28, 31, 33 > Flashcards

Exam 2 Ch. 14, 28, 31, 33 Flashcards

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1
Q

Gait Belt
Who? How?

A

For who? Used for patients with an unsteady gait/generalized weakness
How? Wrapped around waist with two finger space

If the patient has a weak side the nurse should stand on the weak side & hold the belt at the back of the waist.

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2
Q

Canes
Who? How?

A

For who? Used for patients who need additional assistance when walking due to balance problems or weakness
How? Cane should be level at the hip & patient arm should be comfortably bent.

Ambulation: Patient should hold the cane on their stronger & move the cane first, followed by the weaker leg & then stronger leg

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3
Q

Crutches
Who? How?

A

How? Underarm crutch should be placed 2in widths of space between the axilla & the top of the crutch & 6 inches away from the feet, patient elbow should be comfortably bent.

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4
Q

2-point gait
Who? How?

A

For who? Patient can bear partial weight on either or both lower extremities

How? Move one crutch forward simultaneously with opposite leg

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5
Q

3-point gait
Who? How?

A

For who? Injury on one leg
How? Both crutches are placed forward & patient swings their leg to the center, bearing weight on the unaffected leg

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6
Q

4-point gait
Who? How?

A

For who? Patient can bear partial weight on both lower extremities
How? Patient moves one crutch forward followed by the opposing leg and repeat the pattern

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7
Q

Walkers
Who? How?

A

For who? Patients who have weakness or balance issues or are recovering from back & leg injuries
How? Push walker forward with weak leg and patient moves into center with strong leg

Waist high and wider than the patient

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8
Q

Mechanical lifts

A

Can lift clients from bed, chair, toilet, or floor (preferred transfer method); some can be used for ambulation

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9
Q

Isotonic movement

A

Active movement with constant muscle contraction
Ex. Walking, running, swimming

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10
Q

Isometric movement

A

Muscle contraction occurs, but joints stay stationary – good for patients with joint issues
Ex. Keggal, squeezing towel between knees

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11
Q

Aerobic movement

A

Requires oxygen metabolism to produce energy; amount of oxygen into the body is greater than that used to perform the exercise
Ex. Stair climbing

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12
Q

Anaerobic movement

A

Build power & body mass w/o oxygen; Activity in which the muscles cannot draw out enough oxygen from blood stream and anaerobic pathways are use to provide additional energy for a short time
Ex. Heavy weight lifting

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13
Q

Sensory deficits: Tactile

A

Damage of the sensory nerves in the arms/legs which lead to peripheral neuropathy
Common in patients with D.M & renal disease

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14
Q

Sensory deficits: Smell

A

Chemoreceptors decrease due to infections, chronic allergies, smoking & cocaine

Anosmia

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15
Q

Presbycusis

A

Age related hearing loss

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16
Q

Sensory deficits: Taste

A

Gustatory cells declines after the age of 50yrs

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17
Q

Congenital hearing loss

A

Hearing loss that is present at birth
Causes: infections (rubella or herpes simplex virus)

Hearing deficit

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18
Q

Conductive hearing loss

A

Build up of cerumen in the ear canal (Otitis Media)

Hearing deficit

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19
Q

Sensorineural hearing loss

A

Nerve damage in the inner ear/brain

Hearing deficit

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20
Q

Myopia

A

Nearsightedness; cannot see objects far away

Vision deficit

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21
Q

Presbyopia

A

Age related
Farsightedness (decrease the ability to focus on near objects)

Vision deficit

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22
Q

Cataracts

A

Clouding of the lens

Vision deficit

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23
Q

Glaucoma

A

Caused by increased intraocular pressure
Blind spots

Vision deficit

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24
Q

Diabetic Retinopathy

A

Blood vessels of the retina become damaged
Blurry vision

Vision deficit

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25
Q

Macular Degeneration

A

Decrease in central vision
Blurry/fuzzy vision

Vision deficit

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26
Q

Dyssomnias

A

Disorders associated with getting to sleep, staying asleep, or being excessively sleepy

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27
Q

Causes of dyssomnias

A

Too much napping, anxiety, depression, high levels of stimulation at bedtime, medication use, shift work, and hyperthyroidism.

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28
Q

When does a disruption of the normal circadian sleep pattern occur?

A

The person cannot sleep when sleep is wanted, needed, or expected

Common in late night shift work and time zone change (jet lag) situations.

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29
Q

What’s the most familiar circadian rhythm?

A

Day-night, 24-hour circadian rhythm cycle.

30
Q

What are potential consequences of circadian rhythm disturbances?

A

Depression, sexual dysfunction, memory difficulties, high blood pressure, obesity, and an increased risk for accidents

31
Q

What are some cognitive alterations?

A

Disorientation, loss of language and/or simple arithmetic skills, poor judgment, and memory loss

Some decline in cognitive ability occurs with aging, these symptoms are not a normal part of aging

32
Q

Delirium

A

Acute confusion
It is characterized by a disturbance in consciousness or a change in cognition that develops over 1 to 2 days and is caused by a medical condition

33
Q

What does delirium look like?

A

Fluctuating awareness, impairment of memory and attention, disorganized thinking, hallucinations, and disturbances of sleep-wake cycles

34
Q

What causes delirium?

A

Drug or alcohol use, the side effects of medication, infections, fluid and electrolyte imbalances, low oxygen level, and pain

May occur in patients in the intensive care unit (ICU) because of sensory overload. Once the underlying cause of delirium is identified and treated, the confusion subsides.

35
Q

What is depression? What are the 2 types?

A

A mood disorder characterized by a sense of hopelessness and persistent unhappiness
- Major depression is characterized by symptoms on most days for 2 weeks; triggered by a life situation
- Persistent depressive disorder is when symptoms are present for at least 2 years, but might vary in severity

36
Q

What is dementia?

A

A permanent decline in mental function, has a subtle onset
Characterized by the decline in many cognitive abilities, including reasoning, use of language, memory, computation, judgment, and learning
Not reversible and worsens over time
Most common: Alzheimer’s Disease

37
Q

What is a cerebrovascular accident (CVA)?

A

An area of the brain is deprived of blood flow and also is called a stroke; it causes damage to an area of the brain

38
Q

Ischemic stroke - symptoms, F.A.S.T.?

A

Caused by narrowing of a vessel or embolism (blood clot) blocking a vessel

FAST (face, arm, speech, time) to educate the public in stroke recognition

Symptoms: face weakness, arm weakness, and problems with speech

39
Q

Hemorrhagic stroke

A

Caused by bleeding in the brain from a burst aneurysm or traumatic injury

40
Q

Damage to left side of brain during a stroke

A

Loss of sensation and motor function is seen in the extremities on the right side of the body, and problems with speech occur

41
Q

Damage to right side of brain during stroke

A

the loss of sensation and motor function affects the extremities on the left side of the body, and visual–spatial problems occur

42
Q

Receptive aphasia (Wernicke aphasia)

A

(Named for the area of the temporal lobe that interprets language) cannot comprehend written or spoken language
The auditory pathway is intact, but words do not make sense

43
Q

Expressive aphasia (Broca apashia)

A

The damage is to the motor speech area of the frontal lobe.
Patients understand language but are unable to answer questions, name common objects, or express simple ideas

44
Q

Meningitis

A

An infection of the lining of the brain caused by a virus or bacteria

45
Q

When the patient exhibits sudden or rapid changes in behavior or cognition, what are possible causes?

A

A urinary tract infection or pneumonia

46
Q

Health Literacy

A

The patient’s ability to understand medication/medical education

47
Q

Formal teaching

A

One on one situation in an acute care setting. This can be through media, educational groups & goal-directed conversations. The nurse leads the conversation
Planned, goal-oriented
Ex. Vaccination clinic

48
Q

Informal Teaching

A

Spontaneous, in a variety of settings. Learner/patient oriented.
Ex. Patient asks questions about medications, treatment, or procedures.

49
Q

Primary Teaching

A

Health care consumers begin receiving information as children through their primary education
Ex. Dental care, handwashing & nutrition.

50
Q

What is V.A.R.K?

A

An assessment of learning for individuals who have difficulty learning
Verbal, Aura, Read/write & Kinesthetic

51
Q

What is a multimodal learner?

A

An individual who uses more than one style of learning

52
Q

Blooms domain of learning: Cognitive

A

Knowledge and material that is remembered

53
Q

Blooms domain of learning: psychomotor

A

Learning is incorporated with physical movement. The act of demonstrating, like in the lab

54
Q

Blooms domain of learning: Affective

A

Learning recognizes the emotional component of integrating new knowledge
Patient based. values and attitudes.

55
Q

Role of nursing in health literacy

A

We teach prevention of disease, health promotion, provide treatment instructions, clarify information, and coping with limitations.

56
Q

Low health literacy

A

Individuals are unable to comprehend health-related information or instructions and may fail to make appropriate decisions regarding their care

57
Q

High health literacy

A

Demonstration of proficient health literacy; they understand numbers in the context of the patient’s health care, make appts, fill out forms, gather health records and ask appropriate questions to the physicians

58
Q

Isokinetic movement

A

Muscle contraction or tension against resistance
Ex. using a leg machine at the gym

59
Q

Anti-embolism hose

A

Used to prevent edema to lower extremities, deep vein thrombosis and venous stasis, promote blood flow of venous return, prevent pulmonary emboli

Put on patient before they get out of bed

60
Q

Active ROM

A

perform each ROM to the point of slight resistance but never to the point of discomfort

61
Q

Passive ROM

A

supine or lateral position when performing, expose only limb being exercised, support limb above and below the joint
Goal: maintain joint mobility

62
Q

Flexion

A

Decreasing the angle of the joint

63
Q

Extension

A

Increasing the angle of the joint

64
Q

Hyperextension

A

further extension or straightening of a joint

65
Q

Abduction

A

movement away from the midline

66
Q

Adduction

A

movement toward midline

67
Q

Eversion

A

turn foot outwards

68
Q

Inversion

A

turn foot inwards

69
Q

Pronation

A

palm faces downward

70
Q

Supination

A

palm faces upward (elbow joint)

71
Q

Sensory deprivation

A

Patient may appear bored, restless, disinterested w/ a decreased ability to think

72
Q

Sensory overload

A

Patient will have anxiety, attention deficit, and confusion

Fundamentals of Nursing II (1 decks)

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