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NUR155 > Exam 3 Review > Flashcards

Exam 3 Review Flashcards

1
Q

What are 2 clinical manifestations for hypoxia?

A

Rapid pulse, rapid shallow breaths

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2
Q

How are venous ulcers formed?

A

Decreased blood flow returning from the lower extremities to the heart.

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3
Q

Symbolic satisfaction of wishes through nonrational thought

A

Fantasy

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4
Q

Describe sanguineous exudate

A

Dark red drainage (red blood cells)

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5
Q

What physiological changes occur to the heart valves as we age?

A

Calcification and thickening

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6
Q

Discharging pent up feelings on people less dangerous than those who initially aroused the emotion

A

Displacement

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7
Q

Tissue of a wound is reddish/ fragile, where would the culture be obtained

A

Granulation tissue

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8
Q

How do you appropriately clean a wound?

A

Inside move out to avoid contamination

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9
Q

Decrease in cardiovascular impacts of immobility may be obtained through ROM?

A

Dorsiflexion- reduce thrombus formation

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10
Q

Name four types of debridement

A

Sharp
Mechanical
Chemical
Autolytic

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11
Q

The purpose of placing SCDs on clients?

A

Enhance and promote venous blood return towards heart

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12
Q

Where should the depth of a pressure ulcer be measured?

A

Deepest part of wound

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13
Q

What portion is best for patients with dyspnea

A

High fowlers

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14
Q

When do you see sanguineous exudate?

A

Fresh open wound

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15
Q

Client refused medication or treatment, who do you notify?

A

Medical physician

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16
Q

HTN is a modifiable risk factor for heart disease True/ False

A

True

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17
Q

What is the purpose of floating heels?

A

To help prevent skin breakdown

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18
Q

Handling emotional conflicts or internal or external stressors, by a temporary alteration or consciousness or identity

A

Dissociation

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19
Q

Why isn’t heat therapy used in the first 24 hours of injury?

A

Because it increases inflammation and bleeding

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20
Q

Freedom or independence of client exercise without external influence?

A

Autonomy

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21
Q

Poor nutrition affects the skin integrity due to?

A

Decreased protein intake

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22
Q

Your taste sensory is also called

A

Gustatory

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23
Q

Where are diabetic ulcers found?

A

Tops of toes, feet and legs.

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24
Q

What assessment can a nurse administer to assess level of cognition or confusion?

A

MMSE

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25
Q

Medication that liquefies mucous allowing it to be easily coughed up

A

Expectorant

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26
Q

Attempting to take back an unconscious thought or behavior that is unacceptable or hurtful

A

Undoing

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27
Q

What is the minimal amount of exercise an individual should get?

A

30 min aerobic five times/ week

28
Q

BNP is a cardiac enzyme to test for what?

A

CHF– (heart failure)

29
Q

Factors that significantly raise skin breakdown in patients?

A

Age, mobility, moisture, incontinence

30
Q

Dementia is an acute episode of confusion? True/ false?

A

False! Dementia is chronic, delirium is acute

31
Q

Where do you take a culture from an infection?

A

Granulation tissue

32
Q

Later in skin between muscle and adipose tissue

A

Fascia

33
Q

A method used to open collapsed aveoli and loosen secretions is called

A

Incentive spirometer

34
Q

Serum protein (protein in the blood) is nutritional reserve for?

A

Rebuilding cells

35
Q

What are some benefits for exercise for older adults?

A

Increased bone density, increased joint ROM

36
Q

Blocking out painful or anxiety-inducing events or feelings

A

Denial

37
Q

What clients most susceptible to sensory deprivation?

A

Solitary, bed ridden

38
Q

For wounds, can a upsilons be stitched?

A

No!

39
Q

Process of blocking out painful or anxiety inducing events or feelings is called?

A

Denial

40
Q

Is oxygen needed to heal wounds?

A

Yes

41
Q

If an area has excessive body heat what is the body trying to tell you?

A

That the area has an increase need for oxygen

42
Q

A wound that encompasses the epidermis and maybe some of dermis is what?

A

Stage 2 ulcer

43
Q

What finding suggests to the nurse the client is experiencing sensory overload?

A

Rage, insomnia, muscle tension, anxiety attack, seizure, isolation

44
Q

Common risk assessment scale for checking wound-healing status

A

Braden scale

45
Q

Unconscious assumption of similarity between oneself and another

A

Identification

46
Q

Acceptance of another’s values and opinions as ones own

A

Introjection

47
Q

Cardiac enzyme used for MI patients?

A

Troponin

48
Q

What type of clients are at a greater risk for thrombus formation?

A

PVD, obese, smoker, and

sedentary lifestyles

49
Q

Reverting to an earlier stage of development

A

Regression

50
Q

What type of O2 delivery device puts out 95% oxygen to patient?

A

Non-breather face mask

51
Q

Serious respiratory impact from immobility?

A

Pneumonia, pooling respiratory secretions

52
Q

Describe albumin

A

Prolonged protein depletion

53
Q

Chronic illnesses that affect skin integrity

A

PVD, PAD, CAD

54
Q

What does REEDA stand for?

A 
Redness
Edema
Ecchymosis
Drainage
Approximation
55
Q

What is REEDA used for?

A

Wound evaluation

56
Q

What is Santil?

A

A way of debriding dead tissue

57
Q

What is non-maleficence

A

Duty to cause no harm

58
Q

The dermis separates from underlying structures can be described as what type of wound?

A

Skin tear

59
Q

Significant difference between anxiety and fear?

A

Fear has identifiable source, anxiety does not

60
Q

Describe granulation tissue

A

Red healthy tissue with good circulation and profusion

61
Q

How do you measure a pressure ulcer?

A

With a sterile swab stick

62
Q

What is suppuration?

A

The formation of pus

63
Q

Charcots foot can occur from?

A

Neuropathy

64
Q

Describe venous ulcers

A

Wound drainage and irregular wound edges

65
Q

Stress can cause significant decrease in blood glucose levels. True/ False?

A

False

66
Q

What are some characteristics of diabetic ulcers?

A

Irregular wound margins and callous around the wound

NUR155 (2 decks)

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