Final Flashcards
(233 cards)
1
Q
What is subjective data?
A
What the person says about themself EX: nausea, vomiting, dyspnea etc.
2
Q
What is objective data?
A
What you as the health professional observe through inspection, palpation, lab values etc.
3
Q
What is diagnostic reasoning?
A
The process of analyzing health data and drawing conclusions to identify diagnosis.
4
Q
What phases are in the nursing process?
A
Assessment Diagnosis Outcome identification planning implementation evaluation
5
Q
What is the assessment portion of the nursing process?
A
Collect data and document
6
Q
What is diagnosis part of the nursing process?
A
Compare clinical findings with normal and abnormal variation and developmental events
- interpret data
- validate diagnosis
- document diagnosis
7
Q
What is the outcome part of the nursing process?
A
- Identify expected outcomes
- Individualize the person
- Identify expected culturally appropriate outcomes
- establish realistic and measurable outcomes
- develop a timeline
8
Q
What is the planning part of the nursing process?
A
- Establish priorities
- Develop outcomes
- Set timelines for outcomes
- Identify interventions
- integrate evidence-based trends and research
- document plan of care
9
Q
what is the implementation part of the nursing process?
A
- implement in a safe and timely manner
- Collab with colleagues
- use community resources
- Coordinate care delivery
- Provide health teaching and health promotion
- Document implementation and any modification
10
Q
What is the evaluation part of the nursing process?
A
- Progress toward outcomes
- conduct a systemic, ongoing, criterion based evaluation
- Include patient and significant others
- Determine results to patient and family
11
Q
How many levels are there when setting priorities?
A
3 Levels
12
Q
What is a first priority problem?
A
High priority, such as airway, breathing, and circulation
13
Q
What is a second level priority?
A
Mental status, acute pain, infection risk, abnormal lab values, and elimination problems
14
Q
What is a third level priority?
A
Lack of knowledge, mobility problems, and family coping.
15
Q
What is evidence based practice?
A
The conviction that all patients deserve to be treated with the most current and best practice techniques led to development of EBP
16
Q
what is holistic health?
A
Consideration of the whole person (mind, body, and spirit)
17
Q
What does sending and receiving mean in the interview process?
A
Sending means to be aware of your verbal communication such as your verbage, tone, facial expressions; but sending is not the only thing with communication it also requires that the receiver understands and can process what you are sending.
18
Q
What are some factors of the physical environment when conducting an interview?
A
- comfortable room temp
- sufficient lighting
- quiet environment
- remove distractions
- 4 to 5 ft of distance
19
Q
Should you ask open ended or close ended questions?
A
open ended to allow narrative
20
Q
What are the 10 traps of interviewing?
A
- providing false assurance
- Giving unwanted advice
- using authority
- using avoidance language
- distancing
- using professional jargon
- Using leading or biased questions
- talking too much
- interrupting
- using why questions
21
Q
What is health literacy?
A
the ability to understand instructions, navigate the health care system and communicate concerns with the health care provider
22
Q
What does SBAR stand for?
A
Situation
Background
Assessment
Recommendation
23
Q
When assessing symptoms what information should you be attaining? (8 items)
A
- Location
- Character or quality of the pain
- Quantity or severity
- Timing
- Setting
- Aggravating or relieving factors
- Associated factors
- Patients perception
24
Q
describe a mental organic disorder.
A
Caused by brain disease of known specific organic cause (dementia, alcohol, drugs)
25
Explain psychiatric mental disorder
In which an organic etiology has not yet been established. (anxiety, schizophrenia etc)
26
What are the two ways to calculate BMI?
BMI=weight (pounds)/Height (inch) x 703
| BMI= Weight (kilo)/ Height (meters)2
27
What BMI is classified as underweight?
<18.5 kg/m2
28
What BMI is classified as normal?
18.5 to 24.9 kg/m2
29
What BMI is classified as overweight?
25 to 29.9 kg/m2
30
What BMI is classified as Obese (class 1)?
30 to 34.9 kg/m2
31
What BMI is classified as obese (class 2)?
35 to 39.9 kg/m2
32
What BMI is classified as extreme obesity?
>= 40 kg/m2
33
What are the two main processes pain develops by?
Nociceptive and and or neuropathic
34
What is acute pain?
- Less than 3 months
| - Short term- Injury, protective to prevent further injury, sudden
35
What is Chronic pain?
- Not helpful
- Long term
- Greater than 3-6 months
36
What is cutaneous pain?
-Sharp/ Burning skin pain
37
What is somatic pain?
-Pain associated with muscle and bone, deeper, aching
38
What is visceral pain ?
-Organ pain, diffuse, hard to localize, frequent and severe
39
What is radiating pain?
-Pain that moves
40
What is referred pain?
-Pain that is in a different location than the injury or offense
41
What is intractable pain?
- Pain that is difficult to treat
| - Pancreatitis, cancer
42
What is neuropathic pain?
- Pain in the nerves, strangulation or starvation of a nerve
| - herpes, back injury, neuro disorders
43
What is phantom pain?
Pain in a place that the limb no longer exists in amputees
44
What is the priority when it comes to pain?
What will kill them?
| What will keep them alive?
45
In a pain assessment what does PQRST stand for?
- Provocation (Palliation, precipitating factors)
- Quality, Quantity
- Region, radiation
- Severity, pain scale
- Time scale
46
What does OLDCART stand for?
```
Onset
Location
Duration
Characteristics
Aggravating factors
Relieving factors
Treatments
```
47
What does ICE stand for?
- Impact (on daily living)
- Coping stratagies
- Emotional response (sad, anxiety)
48
What are food restrictions of Buddhism?
- All meat
- Alcohol
- Pungent spices (garlic, onion, scallions, chives, leeks)
49
What are the food restrictions of Catholicism?
- Meath on some denominational holidays
| - Alcohol
50
What are the food restrictions of Hinduism?
- Lacto-vegetarianism often favored
- Alcohol and intoxicating substances
- Garlic, onion and spicy foods
- fasting on some holidays
51
What are the food restrictions of the Islam?
- All pork and pork products
- Meat (not slaughtered)
- Alchohol
- Coffee and tea
52
What are the food restrictions for mormons?
- Alcoholic beverages
| - Hot bevs, coffee and tea
53
What are the food restrictions for orthodox judaism?
- all pork and pork products
- Meat (not slaughtered)
- All shellfish
- Dairy and meat at the same time
- Leavened bread and cake during passover
- Food and bev on yom kippur
54
What are the food restrictions of seventh day adventist?
- all pork and pork products
- shellfish
- meat
- dairy
- alcohol
55
What does cyanosis of the skin mean?
Decreased oxygen results in a bluish tone
56
What does blanch skin mean?
Push on the skin and it turns lighter
57
What is Hurtuism?
Overgrowth of hair
58
What is the ABCDE for skin stand for?
```
Asymmetry
Border
Color
Diameter
Elevation and evolution
```
59
What is alopecia?
Loss of hair in random areas
60
What is HSV-1?
Oral herpes
61
What is HSV-2
Genital herpes
62
When assessing the hair what do you look for?
```
Color
Distribution
Thickness/ texture
Dry
Bleached of dyed
```
63
Describe the epidermis
- Thin but tough
| - formed by the basal cel layer, horny cell layer
64
Describe the dermis
- supportive layer consisting mostly of connective tissue or collagen
- enables the skin to resist tearing
65
Describe the subcutaneous layer
- adipose tissue
- stores fat for energy
- provides insulation and temp control
66
What is an eccrine sweat gland?
-coiled tubules that open directly onto the skin surface and produce a dilute saline solution called sweat
67
What is the apocrine sweat gland?
-glands that produce a thick milky secretion and open into the hair follicles
68
Describe and annular lesion
-circular, beings in center and spreads
69
What is a confluent lesion?
Lesions that run together
70
What is a gyrate lesion?
Twisted, coiled, spiral, snakelike
71
What is a zosteriform lesion?
Linear arrangement along unilateral nerve route
72
What is a macule?
Solely a color change, flat and circumscribed
| EX: freckles
73
What is a papule?
Something you can feel; elevated
| EX: mole
74
What is a patch?
Macules that are larger than 1cm
| EX: Mongolian spot, vitiligo
75
What is a plaque?
Papules coalesce to form surface elevation wider than 1cm
| EX: psoriasis, lichen
76
What is a nodule?
Solid, elevated hard or soft, larger than 1cm
77
What is a wheal?
superficial raised, transient, slightly irregular shape from edema
78
What is a tumor?
Larger than a few cm in diameter, firm or soft, deeper into dermis
79
What is Utircaria?
Hives
80
What is a vesicle?
Elevated cavity containing free fluid
| EX: blister
81
What is a Bulla?
Larger than 1cm diameter
superficial in epidermis, thin walled
EX: friction blister
82
What is a cyst?
Encapsulated fluid filled cavity in dermis or subcutaneous layer
83
What is a pustule?
Turbid fluid (pus) in the cavity
84
What is a keloid?
A benign excess of scar tissue beyond sites of original injury Most occurs in darker people
85
How many stages are there in ulcers? and what do they mean?
Stage 1: Intact, skin is red
Stage 2: loss of epidermis
Stage 3: PI extends into subcutaneous tissue
Stage 4: Full thickness and tissue loss
86
True of false: the head should be midline and normociphalic
True
87
What are the fontanels in a baby?
Anterior
| posterior
88
When does the anterior fontanel close?
9 months to 2 years
89
When does the posterior fontanel close?
2 months
90
What is the metabolic master?
Thyroid
91
Does hyperthyroidism increase or decrease metabolic rate?
Increase
92
Does hypothyroidism increase or decrease metabolic rate?
Decrease
93
If a patient had wt loss, exophalmos, insomnia and is tachycardic does this patient have hyperthyroidism or hypothyroidism?
Hyperthyroidism
94
If a patient has increased wt gain, fatigue, periorbital edema , constipation and is bradycardic does the patient have hyperthyroidism or hypothyroidism?
Hypothyroidism
95
What is a migraine?
```
Vascular
Sensitive to light
most common in females
most common one sided and behind eye
gradual onset lasts 30 min to days
```
96
What is a tension headache?
```
Muscloskeletal
band like
constant/ throbbing
stress
peaks 1-2 hr and lasts 4-72
```
97
What is a cluster headache?
```
Unilateral
Burning/ piercing
multiple in a day
More rare
peaks and lasts 45-90 min
```
98
What is hydrocephalus?
Obstruction of drainage of the cebrospinal fluid; results in increase intercranial pressure
99
What are some characteristics of down syndrome?
```
upslanting eyes
inner epicantal folds
flat nasal bridge
thick tongue
short broad neck
```
100
What does PERLA stand for?
```
Pupils
Equal
Round
Reactive
Light
Accommodation
```
101
What color should the sclera be?
White
102
What color should the conjunctiva be?
Pink
103
What does jaundice in the eyes indicate?
Liver
| hemolytic
104
What does pink sclera indicate?
irritation
infection
allergies
105
What does red conjunctiva indicate?
Inflammation and infection
106
What does pallor mean in relation to the eyes?
Decrease in 02 blood flow
Decrease in BP
Anemia
107
What does exophalmos mean?
Bulging eyes
108
What does periorbital edema stand for?
Edema around eyes
| puffy
109
What does ptosis stand for?
Drooping
| EX: Bells palsy or stroke
110
What does glaucoma mean?
Increased pressure in the eyeball
very painful
pupil misshapen
peripheral vision loss
111
Does glaucoma make you lose peripheral vision or central vision?
peripheral
112
What is Macular degeneration?
Loss of central vision
| caused by diabetes
113
What is cataracts?
#1 cause of curable blindness
114
What is presbypia?
Loss in near vision in older people
115
What does nystagmus mean?
Wiggling eyes
116
What is mydriasis?
Dialated pupil
| caused by meth, cocaine
117
What is miosis of the eye?
Shrinking of the pupil
| Caused by narcotics such as morphine etc
118
Is the snellen test used for near vision or far vision ?
Far
| 20ft away
119
Is the Rosenbaum test used for near or far vision
Near
| 12 -14 inches away
120
Is the image formed in the retina upside down or right side up?
upside down
121
What is a tophi?
Build up of uric acid
122
What happens when you prop a bottle?
Ear infections
| baby tooth decay
123
When inspecting the tympanic membrane in adults what do you do?
pull up and back
124
When inspecting the tympanic membrane in infants what do you do?
pull down and back
125
What are you looking for when inspecting the tympanic membrane?
pearly gray
translucent
flat
intact
126
What would indicate the tympanic membrane is infected
cloudy or reddness
127
How do you avoid tophi?
avoid pork
128
what is cerumen?
Ear wax
129
What color should ear wax be in Caucasians?
orange and waxy
130
What ethnicity has a decrease in ear wax and tends to be more flaky?
Asians
131
What ethnicity has gray /tan and flaky ear wax?
African americans
132
T or F: effusions get abx
False
133
What is Rinne?
Vibration
| air conduction to bone conduction 2:1
134
What is Vertigo? and how is it tested?
Trouble balancing
| tested through the rhomberg test
135
What is otitus media?
Inner ear infection
Pain on swallowing
Observe change in tympanic membrane (reddish, pinkish, yellowish)
136
What is otitus externa?
```
Outer ear infection
Pain on palpation
drainage
inflammation
AKA swimmers ear
```
137
What is Halo?
Head trauma and ear bleeding
| Blood surrounded by CSG
138
What is defined as "old hearing"
Presbycusis
| Decrease in high frequency hearing
139
What is tinitus?
Ringing in ears
| Trauma, loud noises
140
What does COCA stand for?
Color
Odor
Consistency
Amount
141
What does clear nose drainage indicate?
Allergies and or emphysema
142
What does green nose drainage mean?
Infection
143
What causes a perforated septum?
cocaine
| Meth
144
What is anosmia?
Loss of smell
145
What is Epistaxis?
Bloody nose
146
What should you assess on someone with epistaxis ?
HTN and BP
147
What is patency?
Open airway
148
What is rhinitis?
Inflammation of the mucus membrane in the nose
149
What is sinusitis?
Inflamed sinus
150
What is rhinnorhea?
Runny nose
151
What cranial nerve controls the sense of smell?
olfactory
152
If the tonsils are enlarged what does that indicate?
Same color just big
153
If the tonsils are inflamed what does that indicate?
Discolor
154
What is gingivitis?
Inflamed gums
poor hygiene
medications
pregnancy
155
What two things cause a black hairy tongue?
ABX and not brushing
156
What is thrush?
Yeast infection
| Common in breastfed children
157
What is leukoplakia?
Pre cancerous
| dysplastic cells
158
What does it mean to have trouble speaking?
Dysphasia
159
What does it mean to have trouble swallowing?
Dysphagia
160
What does dry mucus membranes in the mouth indicate?
Dehydration
anemia
hypovolemia
meds- SNS stimulants
161
What is cleft lip palate?
Neutral tube defect
| folic acid deficiency before pregnancy
162
What angle should the anterior chest be assessed at?
45*
163
What should the AP:T be?
1:2
164
Where should you percuss?
posterior chest and ribs
165
What is the name of the sound you should hear when percussing?
Resonance
166
Is inhalation active or passive?
Active
167
Is exhalation active or passive?
Passive
168
What does a greater than 90* costal vertebral angle indicate?
Barrel chest
169
What drives us to breathe?
CO2 levels
170
What do crackles mean?
Fluid or mucus in the alveoli
171
What does absent breath sounds mean?
No airflow or ventilation occurring in that area
172
What does wheezes mean?
Turbulent airflow in the airways (trachea/ bronchiols)
173
What does diminished breath sounds mean?
Decrease in airflow or excess tissue often indicates atelectasis
174
What is hyper-resonance?
Loud hollow sound on percussion means excess air/space often emphysema or pneumonia
175
What does it mean if a percussion is dull?
over an organ
176
What does it mean if a percussion is flat?
Over a bone
177
What does crepitus mean?
A crackle feeling on palpation of chest occurs after a pneumothorax
178
What is the leading cause of asthma in children?
2nd and 3rd hand smoke
179
How do you calculate someones pack year?
packs per day x # yrs smoked = pack year
180
What is another name for crackles?
Rales
181
What disease process creates crackles (rales)?
Pulmonary edema
| pneumonia
182
What disease process creates wheezes?
asthma
| bronchitis
183
What disease process creates absent breath sounds?
pneumothorax
pleural effusion
hemothorax
obstruction
184
What disease process creates diminished breath sounds?
obesity
emphysema
atelectasis
185
What disease process creates stridor?
aspiration
| laryngitis
186
What is a pleural rub?
inflammation of the pleura
187
What does all people love time magazine mean?
```
Aortic
pulmonary
erbs
tricuspid
mitral
```
188
What does S1 mean?
Closure of atrial valves
189
What does S2 mean?
Closure of semilunar valves
190
What is a murmur?
Turbulent bf over a valve
191
What is a bruit?
turbulent bf over an artery (swooshing)
192
When does s3 occur?
During diastole
| forceful filling of ventricle
193
When does s4 occur?
When indicating a major heart issue
194
What does the lub mean?
Pump ventricular contraction
195
What does the dub mean?
Fill- ventricular relax
196
What are common signs of left sided heart failure?
```
HA
orthopnea
pulse deficit
Cyanosis
pain (dull, achy)
Crackles
pink frothy sputum
```
197
What are common signs indicating right sided heart failure?
```
Fatigue, HA, confusion
JvD
Dyspnea
Gastro stress
Hepsplenomegaly
Increase in capillary refill time
edema
acites
```
198
What is ascites?
Abdominal swelling
199
What is atherosclerosis?
Pathogen change
plaque and increase in LDL
HTN
200
What is arteriosclerosis?
Physiologic change
201
What are the symptoms of MI?
decrease perfusion
increase in BP
Neurologic
Angina
202
When assessing a pulse what are you looking for?
Rate
Rhythm
Symmetry
Amplitude
203
What rhythm indicates death?
Asystole
204
What rhythm indicates a shock needs to happen?
Ventricular fibrillation
205
What causes atrial fibrillation?
Stroke
206
What is arterial flutter?
Regularly, irregular rhythm
207
What is the definition of hyperventilation??
Movement of large volumes of air
208
What is the definition of hypoventilation?
Movement of small volume of air
209
What does orthopnea mean?
Difficulty breathing laying down
210
What does tachypnea mean?
Breathing quickly
211
What does bradypnea mean?
Breathing slowly
212
What does cheyne stokes mean?
End of life breathing
213
What does atrial fibrillation mean?
Failure of the atria to contract
214
What is hypotension?
Inadequate perfusion to the brain or organs accompanied by a lower than usual BP
215
What is hypertension?
BP greater than 119/79
216
What is tachycardia
HR over 100
217
What is bradycardia?
HR less than 60
218
What is pulse deficit?
Apical pulse that is higher than a peripheral pulse
219
What is heart failure?
Inability of the heart to meet metabolic demand
220
What is a myocardial infarction?
Death of heart cells
221
What is atelectasis ?
Collapse of individual alveoli
222
What is pnemothorax?
Collapse of lobe of a lung
223
Which patient has onset left sided HF?
A. JVD, crackles, venous hum over the inferior vena cava
B. Hyper-resonance over lung fields, ascites, pulse deficit
C.Crackles, elevated temp, productive cough
D. Crackles, orthopnea, productive cough
D.Crackles, orthopnea, and productive cough
224
Which pt should be assessed immediately?
A. A rt hip fracture waiting on surgical consult, hip pain 9/10
B. Post appendectomy reporting leg pain 7/10
C. Emphysema exacerbation with o2 sat at 92%
D. Bowel Obstruction stating the NG tube has green stuff in it
B.
225
```
A client presents post traumatic car accident with the following: crepitus, tachypnea, deviated trachea to the right. What do you suspect?
A. left pneumothorax
B. R Atelectasis
C. R Pneumothorax
D. L Atelectasis
```
A
226
```
What can cause pallor?
A. Anemia
B. Raynauds phenomena
C. Venous insufficiency
D. DVT
E. Polycythemia
F. HTN
G. sepsis
```
A,B,G
227
```
What finding are expected with heart failure?
A. Absent Breath sounds
B. Pink frothy sputum
C. Orthopnea
D. JVD
E. Crackles
F. Peripheral edema
G. Carotid bruit
H. Clear breath sounds
```
B,C,D,E,F
228
What is the primary concern with a patient who has pallor?
A. Decreased perfusion of oxygenated blood
B. Decreased oxygen saturation of blood
C. Replacing lost red blood cells
D. Lowering the BP
A
229
```
Which patient has macular degeneration?
A. difficulty seeing near
B. difficulty seeing far
C. Loss of peripheral vision
D. Loss of central vision
```
D
230
What does increased tactile fremitus indicate?
Fluid or consolidation of the lung
231
When do you call a physician?
- When there is an unexpected finding
- When there is an order you want to clarify
- When their condition is worsening
232
```
A client is suffering from hypoxia which assessment finding would the nurse NOT expect?
A. tachycardia
B. Hyperventilation
C. Restlessness
D.Pallor
```
D.
233
Which patient has myopia?
A. difficulty seeing far
B. Only able to read the top line of the snellen chart
C. Only able to read the top line of the rosenbaum chart
D. Loss of central vision
A or B
