Exam 2 Review Flashcards
What are signs of hypothermia?
Bradypnea
Pallor/cyanosis
Delirium
What is the nursing priority for a patient found unconscious experiencing hyperthermia?
Move the patient to a safe location
A homeless man is brought to the ED for hypothermia. What might the nurse expect?
Stupor
A patient has a core temperature of 90° F (32.2° C). The most appropriate rewarming technique would be:
Active internal rewarming using warmed IV fluids
A patient reports abdominal pain and states “I had a temperature of 103.9°F at home.” What is the nurse’s first action?
Assess the patients current vital signs
What actions can be delegated to the LPN/LVN during therapeutic hypothermia for cardiac arrest?
Give acetaminophen (Tylenol) 650 mg PO
Attach rectal temperature probe to cooling blanket control panel
Place cooling blankets above and below the patient
Which finding indicates the nurse should discontinue active rewarming?
The core temperature is 94°F (34.4°C)
What indicates effective discharge teaching in a client admitted for hypotension and hyperthermia?
“I need to drink extra fluids when working outside in hot weather”
What is the nursing prioirty for treating a client with heat cramps?
Rehydrate
What part of the brain is responsible for thermoregulation?
Hypothalamus
What are characteristics of superficial frostbite?
Skin has a crunchy, waxy appearance
Yellow to blueish discoloration
What are nursing actions for a patient with frostbite?
Monitor for edema and elevate the extremity
Administer IV analgesics
Which person is at higher risk for heat exhaustion?
A construction worker working 12 hour days during the summer
The nurse knows the patient is experiencing heat stroke when:
They are tachycardic, hypotensive, and tachypneic
They have altered mental status
The patient’s skin is hot and ashen colored
What is malignant hyperthermia?
Is triggered by anesthetic agents such as
Succinylcholine
Ventricular dyshythmias can occur and is fatal
Results in muscle rigidity
What is the primary method of heat production in newborns?
Brown adipose tissue
Which eye diagnostic test measures intraocular pressure?
Tonometer
What is the average range for intraocular pressure?
10 - 21 mmHg
Which eye structure does cataracts affect?
Lens
Which cranial nerve is responsible for transmitting visual information?
CN II
Which cranial nerves are responsible for eye movement?
CN III IV VI ( 3, 4, & 6)
What is Myopia?
Nearsighted
is the most common visual problem characterized by the inability to visualize distant objects
What is primary prevention related to vision?
Protection
Use of safety devices
Eye protection
Proactive management of chronic conditions
What is secondary prevention related to vision?
Screening
Antibiotic therapy
Vision screens across lifespan
What is tertiary prevention related to vision?
Treatment
Corrective glasses
Contact lenses
Surgical therapy
Effective education for a mother with multiple children diagnosed with bacterial conjunctivitis includes:
Utilize proper hand hygiene to prevent the spread of infection
Cataracts is characterized by:
Impaired vision with abnormal color perception and glare.
Cloudy, opaque lens
What type of eye drops are used for treatment option for acute angle-closure glaucoma?
Miotic eyedrops
Macular degeneration is characterized by:
Gradual loss of central vision
Primary open-angle glaucoma is caused by:
Trabecular meshwork being clogged.
This is the most common type of glaucoma
What are the symptoms & side effects of closed-angle glaucoma?
A sudden, painful onset accompanied by nausea, vomiting, and colored halos around lights.
What are some characteristics of angle closure glaucoma?
Bulging lens due to aging
Sudden, severe eye pain
Treated with iridectomy
What assessment findings are expected in open-angle glaucoma?
Difficulty with accommodation
Gradual loss of peripheral vision
What are appropriate discharge instructions for a patient who just had eye surgery?
Utilize proper hand hygiene and report any yellow/green discharge.
Administer mild analgesics for discomfort
Avoid activities that increase IOP.
The nurse knows the patient understands teaching about Furosemide (Lasix) when they state:
“If i notice ringing in my ears I will call the provider”
When assessing an adults ear canal the auricle should be gently pulled up and backwards to straighten the canal.
True
When assessing the tympanic membrane it appears bulging, red, and landmarks are not visible. What is occurring?
Acute otitis media
A patient being treated for septic shock should be assessed for hearing loss because of which IV medication?
Vancomycin
A patient experiencing discharge in the ear canal and pain should be assessed for:
Swimmer’s ear.
What is the nurse’s first intervention for an elderly patient experiencing hearing loss?
Look for cerumen in the ear
In a patient with vertigo which parts of the ear are most likely involved?
Semicircular canals
Vestibule
Common age-related changes in the auditory system include:
Tinnitus in both ears
Drier cerumen
Auditory nerve degeneration
Atrophy of the tympanic membrane
A patient experiencing conductive hearing loss:
Hears better in a noisy environment
What education should be included for a patient newly fitted for hearing aids?
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.
A nurse is caring for a patient diagnosed with presbycusis. Which assessment finding indicates an adaptation to the sensory deficit?
The patient turns one ear toward the nurse during conversation.
How should the nurse approach a patient experiencing hearing loss?
Write out names or difficult words
Speak normally and slowly
Care for a patient experiencing an acute attack of Meniere’s disease includes:
Administering antiemitics as needed
Keeping the room dark and quiet
Implementing fall precautions
A patient reports being off balance when standing or walking but not while laying down. What term describes this?
Dizziness
Which finding indicates treatment for acute otitis media has been effective?
Tympanic membrane is gray, shiny, and translucent
What assessment question will best allow the nurse to assess for the presence of presbycusis?
“Have you noticed any change in your hearing in recent months or years?”
Which cranial nerve is responsible for processing sound?
CN VIII (8)
Sensorineural hearing loss results from:
malformation or damage to the inner ear.
Heat loss
Radiation
Electromagnetic waves that emit heat from the skin surface to the air.
Heat loss:
Conduction
Transfer of heat through direct contact, from one surface to another.
Heat loss:
Convection
Loss of heat caused by wind currents moving across the body surface
Heat loss:
Perspiration
Evaporation of moisture from the surface of the skin (sweating)
Heat loss
Respiration
Cool ambient air is inhaled and warm air is exhaled
Heat loss
Vasodilation
When the blood vessels open, more blood comes to the skin surface, as result the core temperature decreases.
What is presbycusis?
Hearing loss due to aging.
Otitis media
Is an infection of the TM, ossicles, & space of the middle ear due to swelling of the auditory tube from colds or allergies.
Meniere disease
Is a progressive disorder leading to an accumulation of endolymph in the membranous labyrinth.
Ototoxicity
Is damage to the ear due to certain medications or chemicals leading to hearing loss. (Sensorineural)
Presbyopia
Is the loss of accommodation associated with age.
Normal IOP
10 to 21 mm Hg
IOP in Open-angle glaucoma
22-32 mm Hg
IOP in Acute angle-closure glaucoma
> 50 mm Hg
Increased intraocular pressure may occur due to
increased aqueous humor production by the ciliary process.
Ask patients using eyedrops to treat their glaucoma about
a history of heart or lung disease.
Always assess the patient with an eye problem for
visual acuity.
In a patient with a hemorrhage in the posterior cavity of the eye, the nurse knows that blood is accumulating
Between the lens and the retina
When examining the patient’s eyes, which finding would be of most concern to the nurse?
Small, white nodule on the upper lid margin
Presbyopia occurs in older people because
the lens becomes inflexible, making it difficult to focus on nearby objects.
Before injecting fluorescein for angiography, it is important for the nurse to
obtain an emesis basin
inform patient that skin may turn yellow.
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?
“The cornea of the eye is uneven or irregular with astigmatism.”
Which intervention would be part of the plan of care for a patient who has new vision loss?
Allow the patient to express feelings of grief and anger.
Which patient behaviors would the nurse promote for healthy eyes?
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
What should be included in the discharge teaching for the patient who had cataract surgery?
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.
What is Hyphema?
Is a medical emergency
Due to the collection of blood between cornea and iris. Is it usually due to eye trauma.
Normothermia
Is the normal body temperature 97F-100F
Normothermia
Is the normal body temperature 97F-100F
Hypothermia
Body temperature below >97F (36.2 C)
Hypothermia
Body temperature below <97F (36.2 C)
Hyperthermia
Body temperature above >100F (37.6 C)
Hyperpyrexia
An extremely high body temperature >106.7 F (41.5 C)
Hyperpyrexia
An extremely high body temperature >106.7 F (41.5 C)
Fever
Elevation of the body temperature due to a change in the hypothetical set point
Acrocyanosis
Bluish discoloration of the hands and feet
Hazards of cold stress in infants
Increased oxygen need
Decreased surfactant production
Respiratory distress
Hypoglycemia
Metabolic acidosis
Jaundice
Thermoregulation:
Newborn characteristics leading to heat loss
Skin with little subcutaneous (white) fat
Blood vessels close to the surface
Large skin surface
Populations at greatest risk for problems with
thermoregulation are
Very young
Elderly
Low Socioeconomic status
Persons living in very hot or cold climates
Intervention Strategies for Hyperthermia
Passive strategies
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)
Intervention Strategies for Hyperthermia
Active strategies
Lavage with cool fluids (Active cooling)
Mechanical adjuncts
Administer drug therapy.
Heat Exhaustion clinical syndrome is characterized by
Profuse diaphoresis
Tachycardia
Ashen color
N/V
Heat Exhaustion clinical syndrome is characterized by
Profuse diaphoresis
Tachycardia
Ashen color
N/V
Heat stroke manifestations
Sweat glands stop functioning
>105.8F hyperpyrexia
Absence of prespiration
Hot, dry, ashen skin
Superficial frostbite
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
Superficial frostbite (Passive external warming)
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
Deep frostbite
• 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
Mild hypothermia 93-96.8F
• Passive external (spontaneous) rewarming
Move patient to warm, dry place
remove damp clothing
use radiant lights
place warm blankets on patient
Mild hypothermia 93-96.8F
• Active external (surface) rewarming
Fluid or air filled warming blankets
Warm water immersion
Moderate to severe hypothermia
Active internal or core rewarming
• 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!
What is the risk of rewarming a pt with moderate or severe hypothermia?
• Afterdrop, when peripheral blood returns to central circulation leading to further drop in temperature.
• Hypotension
• Dysrhythmias
When should rewarming be discontinued?
Discontinue rewarming once core temperature reaches 89.6º to 93.2º F (32º to 34º C)
What is the main characteristic of severe hypothermia?
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
What are the treatment priorities of hypothermia?
• 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!
What is malignant hyperthermia?
Hyperthermia with rigidity of skeletal muscles
What causes malignant hyperthermia?
Often occurs with exposure to succinylcholine, especially in conjunction with inhalation agents for anesthesia
Is an autosomal dominant trait.
What is the treatment for malignant hyperthermia?
Dantrolene
