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Health And Illness Concepts 1 > Exam 2 Review > Flashcards

Exam 2 Review Flashcards

1
Q

What are signs of hypothermia?

A

Bradypnea
Pallor/cyanosis
Delirium

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2
Q

What is the nursing priority for a patient found unconscious experiencing hyperthermia?

A

Move the patient to a safe location

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3
Q

A homeless man is brought to the ED for hypothermia. What might the nurse expect?

A

Stupor

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4
Q

A patient has a core temperature of 90° F (32.2° C). The most appropriate rewarming technique would be:

A

Active internal rewarming using warmed IV fluids

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5
Q

A patient reports abdominal pain and states “I had a temperature of 103.9°F at home.” What is the nurse’s first action?

A

Assess the patients current vital signs

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6
Q

What actions can be delegated to the LPN/LVN during therapeutic hypothermia for cardiac arrest?

A

Give acetaminophen (Tylenol) 650 mg PO

Attach rectal temperature probe to cooling blanket control panel

Place cooling blankets above and below the patient

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7
Q

Which finding indicates the nurse should discontinue active rewarming?

A

The core temperature is 94°F (34.4°C)

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8
Q

What indicates effective discharge teaching in a client admitted for hypotension and hyperthermia?

A

“I need to drink extra fluids when working outside in hot weather”

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9
Q

What is the nursing prioirty for treating a client with heat cramps?

A

Rehydrate

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10
Q

What part of the brain is responsible for thermoregulation?

A

Hypothalamus

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11
Q

What are characteristics of superficial frostbite?

A

Skin has a crunchy, waxy appearance

Yellow to blueish discoloration

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12
Q

What are nursing actions for a patient with frostbite?

A

Monitor for edema and elevate the extremity

Administer IV analgesics

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13
Q

Which person is at higher risk for heat exhaustion?

A

A construction worker working 12 hour days during the summer

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14
Q

The nurse knows the patient is experiencing heat stroke when:

A

They are tachycardic, hypotensive, and tachypneic

They have altered mental status

The patient’s skin is hot and ashen colored

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15
Q

What is malignant hyperthermia?

A

Is triggered by anesthetic agents such as
Succinylcholine

Ventricular dyshythmias can occur and is fatal

Results in muscle rigidity

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16
Q

What is the primary method of heat production in newborns?

A

Brown adipose tissue

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17
Q

Which eye diagnostic test measures intraocular pressure?

A

Tonometer

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18
Q

What is the average range for intraocular pressure?

A

10 - 21 mmHg

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19
Q

Which eye structure does cataracts affect?

A

Lens

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20
Q

Which cranial nerve is responsible for transmitting visual information?

A

CN II

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21
Q

Which cranial nerves are responsible for eye movement?

A

CN III IV VI ( 3, 4, & 6)

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22
Q

What is Myopia?

A

Nearsighted

is the most common visual problem characterized by the inability to visualize distant objects

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23
Q

What is primary prevention related to vision?

A

Protection

Use of safety devices
Eye protection
Proactive management of chronic conditions

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24
Q

What is secondary prevention related to vision?

A

Screening

Antibiotic therapy
Vision screens across lifespan

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25
Q

What is tertiary prevention related to vision?

A

Treatment

Corrective glasses
Contact lenses
Surgical therapy

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26
Q

Effective education for a mother with multiple children diagnosed with bacterial conjunctivitis includes:

A

Utilize proper hand hygiene to prevent the spread of infection

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27
Q

Cataracts is characterized by:

A

Impaired vision with abnormal color perception and glare.

Cloudy, opaque lens

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28
Q

What type of eye drops are used for treatment option for acute angle-closure glaucoma?

A

Miotic eyedrops

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29
Q

Macular degeneration is characterized by:

A

Gradual loss of central vision

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30
Q

Primary open-angle glaucoma is caused by:

A

Trabecular meshwork being clogged.
This is the most common type of glaucoma

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31
Q

What are the symptoms & side effects of closed-angle glaucoma?

A

A sudden, painful onset accompanied by nausea, vomiting, and colored halos around lights.

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32
Q

What are some characteristics of angle closure glaucoma?

A

Bulging lens due to aging
Sudden, severe eye pain
Treated with iridectomy

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33
Q

What assessment findings are expected in open-angle glaucoma?

A

Difficulty with accommodation
Gradual loss of peripheral vision

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34
Q

What are appropriate discharge instructions for a patient who just had eye surgery?

A

Utilize proper hand hygiene and report any yellow/green discharge.
Administer mild analgesics for discomfort
Avoid activities that increase IOP.

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35
Q

The nurse knows the patient understands teaching about Furosemide (Lasix) when they state:

A

“If i notice ringing in my ears I will call the provider”

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36
Q

When assessing an adults ear canal the auricle should be gently pulled up and backwards to straighten the canal.

A

True

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37
Q

When assessing the tympanic membrane it appears bulging, red, and landmarks are not visible. What is occurring?

A

Acute otitis media

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38
Q

A patient being treated for septic shock should be assessed for hearing loss because of which IV medication?

A

Vancomycin

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39
Q

A patient experiencing discharge in the ear canal and pain should be assessed for:

A

Swimmer’s ear.

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40
Q

What is the nurse’s first intervention for an elderly patient experiencing hearing loss?

A

Look for cerumen in the ear

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41
Q

In a patient with vertigo which parts of the ear are most likely involved?

A

Semicircular canals
Vestibule

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42
Q

Common age-related changes in the auditory system include:

A

Tinnitus in both ears
Drier cerumen
Auditory nerve degeneration
Atrophy of the tympanic membrane

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43
Q

A patient experiencing conductive hearing loss:

A

Hears better in a noisy environment

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44
Q

What education should be included for a patient newly fitted for hearing aids?

A

Clean the ear molds weekly or as needed
Initially restrict usage to quiet listening in the home
Disconnect or remove the batteries when not in use.

45
Q

A nurse is caring for a patient diagnosed with presbycusis. Which assessment finding indicates an adaptation to the sensory deficit?

A

The patient turns one ear toward the nurse during conversation.

46
Q

How should the nurse approach a patient experiencing hearing loss?

A

Write out names or difficult words

Speak normally and slowly

47
Q

Care for a patient experiencing an acute attack of Meniere’s disease includes:

A

Administering antiemitics as needed

Keeping the room dark and quiet

Implementing fall precautions

48
Q

A patient reports being off balance when standing or walking but not while laying down. What term describes this?

A

Dizziness

49
Q

Which finding indicates treatment for acute otitis media has been effective?

A

Tympanic membrane is gray, shiny, and translucent

50
Q

What assessment question will best allow the nurse to assess for the presence of presbycusis?

A

“Have you noticed any change in your hearing in recent months or years?”

51
Q

Which cranial nerve is responsible for processing sound?

A

CN VIII (8)

52
Q

Sensorineural hearing loss results from:

A

malformation or damage to the inner ear.

53
Q

Heat loss
Radiation

A

Electromagnetic waves that emit heat from the skin surface to the air.

54
Q

Heat loss:
Conduction

A

Transfer of heat through direct contact, from one surface to another.

55
Q

Heat loss:
Convection

A

Loss of heat caused by wind currents moving across the body surface

56
Q

Heat loss:
Perspiration

A

Evaporation of moisture from the surface of the skin (sweating)

57
Q

Heat loss
Respiration

A

Cool ambient air is inhaled and warm air is exhaled

58
Q

Heat loss
Vasodilation

A

When the blood vessels open, more blood comes to the skin surface, as result the core temperature decreases.

59
Q

What is presbycusis?

A

Hearing loss due to aging.

60
Q

Otitis media

A

Is an infection of the TM, ossicles, & space of the middle ear due to swelling of the auditory tube from colds or allergies.

61
Q

Meniere disease

A

Is a progressive disorder leading to an accumulation of endolymph in the membranous labyrinth.

62
Q

Ototoxicity

A

Is damage to the ear due to certain medications or chemicals leading to hearing loss. (Sensorineural)

63
Q

Presbyopia

A

Is the loss of accommodation associated with age.

64
Q

Normal IOP

A

10 to 21 mm Hg

65
Q

IOP in Open-angle glaucoma

A

22-32 mm Hg

66
Q

IOP in Acute angle-closure glaucoma

A

> 50 mm Hg

67
Q

Increased intraocular pressure may occur due to

A

increased aqueous humor production by the ciliary process.

68
Q

Ask patients using eyedrops to treat their glaucoma about

A

a history of heart or lung disease.

69
Q

Always assess the patient with an eye problem for

A

visual acuity.

70
Q

In a patient with a hemorrhage in the posterior cavity of the eye, the nurse knows that blood is accumulating

A

Between the lens and the retina

71
Q

When examining the patient’s eyes, which finding would be of most concern to the nurse?

A

Small, white nodule on the upper lid margin

72
Q

Presbyopia occurs in older people because

A

the lens becomes inflexible, making it difficult to focus on nearby objects.

73
Q

Before injecting fluorescein for angiography, it is important for the nurse to

A

obtain an emesis basin

inform patient that skin may turn yellow.

74
Q

A patient says she was diagnosed with astigmatism. When she asks what that is, what is the best explanation the nurse can give to the patient?

A

“The cornea of the eye is uneven or irregular with astigmatism.”

75
Q

Which intervention would be part of the plan of care for a patient who has new vision loss?

A

Allow the patient to express feelings of grief and anger.

76
Q

Which patient behaviors would the nurse promote for healthy eyes?

A

Protective sunglasses when bicycling
Taking part in a smoking cessation program
Supplementing diet intake of vitamin C and beta-carotene
Washing hands thoroughly before putting in or taking out contact lenses

77
Q

What should be included in the discharge teaching for the patient who had cataract surgery?

A

Eye discomfort is often relieved with mild analgesics.

Notify the provider if an increase in redness or drainage occurs.

Following activity restrictions is essential to reduce intraocular pressure.

78
Q

What is Hyphema?

A

Is a medical emergency
Due to the collection of blood between cornea and iris. Is it usually due to eye trauma.

79
Q

Normothermia

A

Is the normal body temperature 97F-100F

80
Q

Normothermia

A

Is the normal body temperature 97F-100F

81
Q

Hypothermia

A

Body temperature below >97F (36.2 C)

82
Q

Hypothermia

A

Body temperature below <97F (36.2 C)

83
Q

Hyperthermia

A

Body temperature above >100F (37.6 C)

84
Q

Hyperpyrexia

A

An extremely high body temperature >106.7 F (41.5 C)

85
Q

Hyperpyrexia

A

An extremely high body temperature >106.7 F (41.5 C)

86
Q

Fever

A

Elevation of the body temperature due to a change in the hypothetical set point

87
Q

Acrocyanosis

A

Bluish discoloration of the hands and feet

88
Q

Hazards of cold stress in infants

A

Increased oxygen need
Decreased surfactant production
Respiratory distress
Hypoglycemia
Metabolic acidosis
Jaundice

89
Q

Thermoregulation:
Newborn characteristics leading to heat loss

A

Skin with little subcutaneous (white) fat
Blood vessels close to the surface
Large skin surface

90
Q

Populations at greatest risk for problems with
thermoregulation are

A

Very young
Elderly
Low Socioeconomic status
Persons living in very hot or cold climates

91
Q

Intervention Strategies for Hyperthermia
Passive strategies

A

Remove excess clothing and blankets
Remove from hot environment
Provide external cool packs
Avoid shivering
Provide for evaporative cooling
Hydrate with cool fluids (oral or intravenous)

92
Q

Intervention Strategies for Hyperthermia
Active strategies

A

Lavage with cool fluids (Active cooling)
Mechanical adjuncts
Administer drug therapy.

93
Q

Heat Exhaustion clinical syndrome is characterized by

A

Profuse diaphoresis
Tachycardia
Ashen color
N/V

94
Q

Heat Exhaustion clinical syndrome is characterized by

A

Profuse diaphoresis
Tachycardia
Ashen color
N/V

95
Q

Heat stroke manifestations

A

Sweat glands stop functioning
>105.8F hyperpyrexia
Absence of prespiration
Hot, dry, ashen skin

96
Q

Superficial frostbite

A

Skin appears waxy pale yellow to blue to mottled
Feels crunchy and frozen
Tingling, numbness, or burning

Never squeeze, massage, or scrub the injured tissue Remove clothing and jewelry

97
Q

Superficial frostbite (Passive external warming)

A

Immerse affected area in circulating water that is 98.6 to 104º F
Use warm soaks for facial areas • Feels warm with stinging as it thaws
Blisters form within hours
Avoid heavy blankets and clothing
Rewarming is extremely painful
May develop edema

98
Q

Deep frostbite

A

• Involves muscle, bone, and tendon
• Skin is white, hard, insensitive to touch
• Mottling gradually progresses to gangrene
• Immerse in a temperature controlled circulating water bath 98.6º to 104º F

99
Q

Mild hypothermia 93-96.8F
• Passive external (spontaneous) rewarming

A

Move patient to warm, dry place
remove damp clothing
use radiant lights
place warm blankets on patient

100
Q

Mild hypothermia 93-96.8F
• Active external (surface) rewarming

A

Fluid or air filled warming blankets
Warm water immersion

101
Q

Moderate to severe hypothermia
Active internal or core rewarming

A

• Heated, humidified oxygen (up to 111.2ºF)
• Warmed IV fluids (up to 98.6ºF)
• Peritoneal lavage with warmed fluids (up to 113ºF)
• Extracorporeal circulation with cardiopulmonary bypass
• Rapid fluid infuser
• Hemodialysis

Rewarm core before extremities in moderate or severe hypothermia!

102
Q

What is the risk of rewarming a pt with moderate or severe hypothermia?

A

• Afterdrop, when peripheral blood returns to central circulation leading to further drop in temperature.
• Hypotension
• Dysrhythmias

103
Q

When should rewarming be discontinued?

A

Discontinue rewarming once core temperature reaches 89.6º to 93.2º F (32º to 34º C)

104
Q

What is the main characteristic of severe hypothermia?

A

Severe hypothermia (<89.6º F [32º C]) makes the person appear dead
• Undetectable vital signs
• Absent reflexes/pupils fixed and dilated
• Bradycardia, ventricular fibrillation, asystole
• Every effort is made to warm patient to at least 86º F (30º C) before they are pronounced dead

105
Q

What are the treatment priorities of hypothermia?

A

• Manage and maintain ABCs
• Rewarm patient
• Prevent shivering
• Correct dehydration and acidosis
• Treat cardiac dysrhythmias

Treatment should be guided by the symptoms not the reading on the thermometer!

106
Q

What is malignant hyperthermia?

A

Hyperthermia with rigidity of skeletal muscles

107
Q

What causes malignant hyperthermia?

A

Often occurs with exposure to succinylcholine, especially in conjunction with inhalation agents for anesthesia
Is an autosomal dominant trait.

108
Q

What is the treatment for malignant hyperthermia?

A

Dantrolene

Health And Illness Concepts 1 (1 decks)

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