Exam 3 Study Guide Flashcards
pressure ulcer stage where skin is intact with nonblanchable redness
stage 1
pressure ulcer stage where the wound is partial thickness and has gone through the epidermis and part of the dermis
stage 2
pressure ulcer stage where the wound is full thickness through the epidermis, dermis, and part of SQ tissue
stage 3
stage 3 pressure ulcers may have ________ drainage
serosanguinous
pressure ulcer stage where the wound is full thickness down to the bone or muscle
stage 4
stage 4 pressure ulcers may have ______ drainage
purulent
3 things the PUSH tool assesses in pressure ulcer
length x width
exudate
tissue type
ABCDEs of moles
asymmetry
border
color
diameter
evolving/elevation
normal mole diameter
less than 1/4 inch (6 mm)
lesions that are conjoined or running together
confluent lesion
edema stage where there is slight pitting that rebounds immediately
1+
edema stage that is a bit deeper and takes about 15 seconds or less to rebound
2+
edema that pits noticeably deep and takes 15 to 20 seconds to rebound
3+
edema stage that pits very deep and takes longer than 20 seconds to rebound
4+
the primary function of the skin
protect the internal body
vitamin produced by the skin
D
6 categories of the Braden Scale
sensory perception
moisture
activity
mobility
nutrition
friction/shear
score range for Braden Scale
6-23
a score of __ or less on the Braden scale requires intervention
18
inner ear infection
otitis media
otitis media symptoms
red, bulging eardrum
diminished or absent light reflex
fluid or pus
grade __ tonsils are visible
1+
grade __ tonsils are midway between tonsillar pillars and uvula
2+
grade __ tonsils are touching the uvula
3+
grade ___ tonsils are touching each other
4+
lymph nodes in front of ear
preauricular
lymph nodes behind ear
posterior auricular
lymph nodes at base of skull
occipital
lymph nodes next to the carotid pulse
tonsillar
lymph nodes under the jaw
submandibular
lymph nodes under the chin
submental
lymph nodes above the collar bone
subclavicular
lymph nodes under the tonsillar lymph nodes
superficial clavicular
lymph nodes on the side of the neck
posterior cervical chain
lymph nodes on the front of the neck
deep cervical chain
pull pinna ____ and back for adults
up
pull pinna ____ and back for children
down
2 tests to do when you suspect hearing loss in one ear
Weber and Rinnes test
sound waves transmitted by middle and outer ear
conduction hearing
sound waves transmitted by inner ear
sensorineural
where to place the tuning fork in the Weber test
center or patients forehead
in the weber test, if the client reports sound lateralizing to the bad ear, then it is ________ hearing loss
conduction
in the weber test, is the client reports sound lateralizing to the good ear, then it is _______ hearing loss
sensorineural
in the Rinne test, place the base of the tuning fork at the ______ _____ and then the other end at the _____
mastoid process, ear
placing the tuning fork by the mastoid process in the Rinne test tests ______ conduction
bone
placing the tuning fork by the ear in the Rinne test tests _____ conduction
air
normal findings in Rinne test
AC greater than BC
if BC is greater than AC, then it is _______ hearing loss
conductive
OS abbreviation
left eye
OD abbreviation
right eye
damage to the ocular nerve because of high ocular pressure
glaucoma
glaucoma S/E
blind spots, tunnel vision, halos, blurred vision
gradual loss of vision caused by aging and thinning of the membrane on the retina
macular degeneration
condition where the vitreous pulls away from the retina and tears the retina
retinal detachment
retinal detachment causes ______
blindness
clouding and hardening of the lens
cataracts
cataracts S/E
cloudy vision, worse vision at night, fading yellow colors, light and glare sensitivity, halos
signs of hyperthyroidism
weight loss, increased HR, irritable, sweaty
signs of hypothyroidism
weight gain, cold, tired
overgrowth of facial hair on women
hirsutism
small lesion that is flat to skin and red, brown, or tan color
macule
small, solid, raised lesion that is purple or red in color
papule
small thinned walled, raised blister with drainage inside
vesicle
constant malalignment of the eyes
strabismus
an oscillating (shaking) movement of the eyes
nystagmus
difficulty swallowing
dysphagia
inverted lower eye lid
entropion
everted lower lid
ectropion
protrusion of the eyes
exopthalmos
loss of hearing due to age
presbycusis
large or swollen lymph nodes
adenopathy
