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NUR 265 > Final Exam > Flashcards

Final Exam Flashcards

1
Q

Subjective Data

A

what the pt tells you

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2
Q

objective data

A

information that the nurse gathers about a pt
ex. vital signs

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3
Q

primary data

A

client is the primary source of data

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4
Q

secondary data

A

another healthcare provider, family, other support persons, records and reports, etc are the primary sources of data

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5
Q

primary subjective

A

what pt says

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6
Q

secondary subjective

A

family member

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7
Q

primary objective

A

your findings

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8
Q

secondary objective

A

another nurses (or healthcare providers) findings

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9
Q

What are the components of general survey?

A

physical appearance, body structure, mobility, behavior

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10
Q

Complete Assessment

A

complete history and head-to-toe assessment
ex. assessment on admission

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11
Q

Focused Assessment

A

more focus on 1 system
ex. skin, cardiac, respiratory

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12
Q

Follow Up Assessment

A

rapid collection of crucial info
ex. pt comes into ED and the nurse gets a history from the family in order to take care of an emergent situation

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13
Q

Inspection

A

ALWAYS DONE FIRST, done by using sight to gather data, can be used throughout the physical examination, different tools can be used to enhance inspection

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14
Q

Palpation

A

make sure hands are warm, start light to deep, palpate tender areas last

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15
Q

Percussion

A

Flatness- bone or muscle
Dullness- liver, spleen
Resonance- air-filled, i.e lungs(hollow)
Hyperresonance- emphysematous lung
Tympany- air-filled stomach

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16
Q

Auscultation

A

the act of listening to sound produced by the body with an assistive device
ex. listening to bowel sounds through stethoscope

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17
Q

Gender Role

A

the role or behavior learned by a person as appropriate to their gender, determined by the prevailing cultural norms

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18
Q

Gender

A

The sex a person is assigned at birth

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19
Q

Gender Identity

A

The gender that a person identifies with

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20
Q

Pressure Injury Stage 1

A

no break in skin

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21
Q

Pressure Injury Stage 2

A

abrasion, blistering, crater

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22
Q

stage 3 pressure injury

A

skin breakage through epidermis, dermis, and into subcutaneous

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23
Q

stage 4 pressure injury

A

subcutaneous skin breakage, damage to bone, muscle, tendons, sloughing, and escar

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24
Q

unstageable pressure injury

A

escar, sloughing, cannot stage until the wound is cleaned, but you can assess how deep it is

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25
Q

Deep Tissue Injury

A

skin is intact, deep, purplish, may be covered with escar, feels squishy

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26
Q

pressure injury prevention

A
  • inspect the skin daily
  • manage moisture (dry the skin after wiping, incontinence care)
  • skin care (keeping skin clean with mild soaps)
  • minimize pressure (reposition every 2 hours, elevate heels)
  • avoid friction to the skin (utilize TAPS)
  • optimize nutrition and hydration (good nutrition helps to heal wounds)
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27
Q

ABCDE

A

asymmetry (within borders)
border (irregularity)
color (black, variations)
diameter (> 1/4)
evolution (is it getting bigger?)

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28
Q

primary lesions

A
  • appear as a direct result of the disease
  • occur at the onset of the disease
  • macule-petechiae, measles, freckles
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29
Q

secondary lesions

A
  • may develop from primary lesions or result from external trauma
    ex. scratching, infections
  • scales, crusts, ulcers
  • may occur if the primary lesion does not heal
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30
Q

Assessing Hair

A
  • ask if pt colors their hair
  • texture (course, curly, smooth, straight, knotty)
  • distribution (even, sparse)
  • scalp (should be smooth, non tender, and freely moveable)
    -pediculosis (should be free of head lice)
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31
Q

Assessing Nails

A

color- should be pink
shape- should be convex
texture- should be smooth, no ridges
assess capillary refill- should be < 3 seconds
assess for clubbing- nail angle should be about 160°, clubbing = angle > 180°

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32
Q

What are pale nails a sign of?

A

cold, cyanosis

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33
Q

What are black nails a sign of?

A

trauma

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34
Q

What is the correct order of blood through through the cardiac valves?

A

Tricuspid, Pulmonic, Mitral, Aortic

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35
Q

Where are the tricuspid and pulmonic valves located?

A

on the right side of the heart, they flow blood to the body

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36
Q

Where are the mitral and aortic valves located?

A

on the left side of the heart, they flow blood to the lungs

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37
Q

What is S1 and where is it heard the loudest?

A

closing of the mitral and tricuspid valves (lub), loudest at the apex

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38
Q

What is S2 and where is it heard the loudest?

A

closing of the pulmonic and aortic valves, loudest at the base

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39
Q

Right Sided Heart Failure Characteristics

A
  • right chamber has lost the ability to pump
  • fatigue
  • high peripheral venous pressure
  • Ascites
  • Enlarged liver and spleen
  • weight gain
  • may be secondary to chronic pulmonary problems
  • distended jugular veins
  • anorexia and complaints of GI distress
  • dependent edema (swelling when legs are down)
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40
Q

Left Sided Heart Failure Characteristics

A
  • blood received from lungs loses ability to contract
  • Paroxysmal nocturnal dyspnea
    (SOB at night, typically when lying down)
  • elevated capillary wedge pressure
  • pulmonary congestion (cough, crackles, wheezes, blood tinges sputum, tachypnea)
  • restlessness
  • confusion (O2 saturation comprimised)
  • orthopnea
  • tachycardia
  • exertional dyspnea
  • cyanosis (decreased O2)
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41
Q

Cardiovascular assessment: normal vs. abnormal findings

A
  • Assessment of carotid artery- should not be able to be seen
    abnormal = bulging
    auscultate for bruit and venous hum
  • Assessment of jugular vein- assess supine at 45° angle, assess for fullness and pulsations (abnormal)
  • Assessment of precordium- no pulsations should be visible except for at the PMI, should not see any heave or lift
  • Auscultation- should not hear murmurs
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42
Q

Peripheral Vascular Developmental Considerations for Pregnant Women

A
  • Blood pressure decreases because of hormonal changes, peripheral vessels dilate
  • lower extremity edema and varicosities in legs because of enlarged veins
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43
Q

Peripheral Vascular Developmental Considerations for Older Adults

A
  • increase in systolic BP
  • blood vessels become rigid
  • arteries calcify (arteriosclerosis, stenosis)
  • arterial walls lose elasticity and vasomotor tone
  • superficial vessels become more prominent (varicosities)
  • increased peripheral vascular resistance
  • decreased venous return (orthostatic BP changes)
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44
Q

Lymphedema Assessment and Interventions

A
  • caused by removed lymph nodes, breast cancer
  • radiation can destroy lymph nodes
  • prevent with compression hose, physical activity, and massage
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45
Q

Arterial Ulcer vs. Venous Ulcer

A

Arterial:
- deep, crusty nails

Venous:
- border always irregular

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46
Q

Where do arteries take blood?

A

away from the heart

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47
Q

Where do veins take blood?

A

to the heart

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48
Q

Characteristics of Peripheral Venous Disease

A
  • normal skin temp
  • increased edema
  • dry and flaky skin with brownish discoloration
  • hair present
  • leg elevation lessens pain
  • wounds occur secondary to inadequate functions of system
  • wounds are initially superficial, irregular in shape
  • wounds are proximal to the medial malleolus
  • pedal pulses normal
  • nails are normal
  • pain is mild to moderate
  • pain increases at the end of the day as edema increases
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49
Q

Characteristics of Peripheral Arterial Disease

A
  • skin temp decreased
  • normal edema
  • tissue thin and shiny
  • hair loss
  • leg elevation increases pain, dangling decreases pain
  • wounds due to ischemia from lack of oxygenated blood
  • wounds lack granulation tissue, smooth edges that are well defined
  • ulcers on lateral malleolus, lower third of leg, toes, web spaces
  • pedal pulses diminished
  • yellow thickened nails
  • severe pain
  • pain with walking, relieved with rest
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50
Q

Where are bronchial sounds located?

A

over the body of the sternum

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51
Q

Where are bronchovesicular sounds located?

A

between the first and second intercostal spaces of the anterior chest

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52
Q

Where are vesicular sounds located?

A

below the second rib at the base of the lungs

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53
Q

Normal vs. Abnormal Inspection of the Lungs

A

Normal:
- no use of accessory muscles
- no nasal flare
- respirations 12-20
- relaxed position
- relaxed facial expression

Abnormal:
- retraction
- use of accessory muscles
- barrel chest
- pectus excavatum/carinatum
- scoliosis, kyphosis

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54
Q

What is the AP: Lateral ratio?

A

1:2

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55
Q

Name some abnormal respiration patterns

A

sigh, tachypnea, bradypnea, hyperventilation, hypoventilation, Cheyne-Stokes, Biot’s

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56
Q

Normal vs. Abnormal Palpation of the lungs

A

Normal:
- symmetric chest expansion
- tactile fremitus

Abnormal:
- crepitus
- pain

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57
Q

Normal vs. Abnormal Palpation of the lungs

A

Normal:
- symmetric chest expansion
- tactile fremitus (equal vibration on both sides)

Abnormal:
- crepitus
- pain

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58
Q

Normal vs. Abnormal Lung Auscultation

A

Normal:
- clear

Abnormal:
- crackles: course and fine
- wheezes
- stridor
- pleural friction rub

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59
Q

What order should bowel sounds be assessed in?

A

RLQ, RUQ, LUQ, LLQ

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60
Q

What position should the patient be in for an abdominal assessment?

A

supine with legs bent to reduce tension

61
Q

What is the sequence of an abdominal assessment?

A

inspection, auscultation, percussion, palpation

62
Q

What are the normal and abnormal abdomen contours?

A

Normal: flat and rounded
Abnormal: scaphoid and protuberant

63
Q

What are some abnormal abdominal findings?

A
  • umbilical, epigastric, and incisional hernias
  • diastasis recti
  • abdominal distention (obesity, air/gas, ascites, ovarian cyst, pregnancy, feces, tumor)
64
Q

hypoactive bowel sounds

A

<5 bowel sounds per minute

65
Q

hyperactive bowel sounds

A

> 30 sounds per minute

66
Q

normoactive bowel sounds

A

5-30 sounds per minute

67
Q

What is the expected finding of percussing the costovertebral angle?

A

no costovertebral angle tenderness

68
Q

What are abnormal findings of percussion of the costovertebral angle?

A
  • pain or tenderness
  • kidney infection
  • musculoskeletal problems
69
Q

Rebound Tenderness/Blumberg Sign

A
  • symptom of appendicitis
  • tests for peritoneal irritation
  • warn the patient before beginning
  • press deeply on the abdomen, then after a moment, quickly release pressure. If it hurts more upon release, the patient has rebound tenderness
70
Q

Normal Stool Findings

A
  • brown
  • soft consistency
  • Newborn- meconium
71
Q

Abnormal Stool Findings

A
  • black tarry
  • red
  • clay (lack of bile/blocked bile duct)
  • yellow or greasy
  • diarrhea
  • constipation
  • fecal impaction (leaking stool)
  • pinworms
72
Q

Female GU Assessment

A

External inspection-
- skin color
- hair distribution
- labia majora
- lesions
- clitoris
- labia minora
- urethral opening
- vaginal opening
- perineum
- anus

73
Q

What are the axillary nodes called?

A

central, pectoral, subscapular, lateral

74
Q

Male GU Assessment

A

Penis:
- inspect skin for lesions
- discharge
- pubic hair pattern, infestation

Scrotum
- Skin
- any mass or lumps

Perianal Area
- skin
- anal opening

75
Q

Testicular Exam

A

should be no masses, pain

76
Q

Female Breast Exam

A
  • Inspect general appearance
  • skin
  • lymphatic drainage areas
  • nipple
  • maneuvers to screen for retraction
  • axillae
  • should be no masses, pain
77
Q

Muscle strength 5/5

A

full ROM against gravity, full resistance

78
Q

muscle strength 4/5

A

full ROM against gravity, some resistance

79
Q

muscle strength 3/5

A

full ROM with gravity

80
Q

muscle strength 2/5

A

full ROM with gravity eliminated (Passive motion)

81
Q

muscle strength 1/5

A

slight contraction

82
Q

muscle strength 0/5

A

no contraction

83
Q

What are some developmental considerations about an infant’s spine?

A
  • C shaped
  • observe for tuft of hair or dimple
    • spina bifida
84
Q

What are some developmental considerations for a toddler, preschooler, or school age child, for the musculoskeletal system?

A
  • lordosis
  • genu varum(bow legged)
  • genu valgum(knock knees)
  • pes planus(flat feet)
  • pigeon toes
  • subluxation(nurse maids elbow)
85
Q

What are some developmental considerations about adolescents for the musculoskeletal system?

A
  • sports injuries
  • tech neck
  • scoliosis
  • kyphosis
86
Q

What are some developmental considerations about pregnant women for the musculoskeletal system?

A
  • lordosis
  • forward cervical flexion
  • waddling
87
Q

What are some developmental considerations about aging adults for the musculoskeletal system?

A
  • decrease in height
  • shortening of trunk
  • dorsal kyphosis
  • base of support broader
  • reduction in total muscle mass
  • decrease in fat in periphery, more in hips/abdomen
88
Q

How to assess cranial nerve 1

A

close one nostril at a time and give familiar smells

89
Q

anosmia

A

loss of sense of smell

90
Q

How to assess cranial nerve 2

A
  • test visual acuity
  • peripheral vision
91
Q

how to assess cranial nerves 3, 4, 6

A
  • pupil accommodation and reaction to light (direct and consensual)
  • extraocular eye movement
92
Q

how to assess cranial nerve 5

A

sensory function:
- touch face with cotton ball and repeat with a toothpick

motor function:
- move jaw side to side against resistance then clench or bite down

93
Q

how to assess cranial nerve 7

A

sensory function

motor function
- smile, frown, eyebrow movement

94
Q

how to assess cranial nerve 8

A

Hearing- whispered voice test
Equilibrium- Romberg test

95
Q

how to assess cranial nerves 9 and 10

A
  • testing motor function: say ahhhhh
  • stimulate gag reflex: needed to prevent choking
  • test taste posterior tongue
96
Q

how to assess cranial nerve 11

A

motor function of neck and shoulder muscles against resistance

97
Q

how to assess cranial nerve 12

A
  • protrude tongue and move it side to side, up and down
  • pronounce L, D, N, T
98
Q

stereognosis

A

recognition of familiar object by touch

99
Q

graphesthesia

A

identify number or letter traced in the hand

100
Q

discriminatory sensations

A

point localization: ability to sense and locate area being stimulate

101
Q

0/4 deep tendon reflex

A

no response detected

102
Q

1/4 deep tendon reflex

A

response present but diminished

103
Q

2/4 deep tendon reflex

A

response normal

104
Q

3/4 deep tendon reflex

A

response somewhat stronger than normal

105
Q

4/4 deep tendon reflex

A

response hyperactive with clonus

106
Q

clonus

A

the presence of rhythmic involuntary contractions

107
Q

normal response for bicep deep tendon reflex

A
  • contraction with flexion of forearm
  • arm needs to be flaccid
108
Q

Tricep reflex

A

abduct pt’s arm and flex it at the elbow. support it with non-dominant hand. strike tendon about 1-2 inches above olecranon process approaching it from directly behind
- make sure arm is limp

109
Q

brachioradialis reflex

A

rest pt’s arm on his/her leg and palpate brachioradialis tendon 3-5 cm above wrist. strike with reflex hammer
- arm needs to be limp

110
Q

tendon reflex

A

client sits with legs dangling. strike tendon directly below patella

111
Q

achilles reflex

A

have client lie supine or sit with one knee flexed. holding the foot slightly dorsiflexed, strike achilles tendon
- should see plantar flexion of foot

112
Q

superficial reflexes: Babinski

A
  • plantar flexion of toes
  • positive = toes fan, not good in adults, normal in children
  • negative = no response/ foot withdraw, toes curl, normal for adult
113
Q

sucking

A

stimulate lips

114
Q

rooting

A

stroke cheek

115
Q

palmar grasp

A

place finger in newborn’s hand and they should squeeze

116
Q

plantar reflex

A

press thumb on bottom of foot and toes should curl down

117
Q

moro reflex

A

startle

118
Q

tonic neck reflex

A

turn head side to side in supine position

119
Q

stepping reflex

A

marching when being help up

120
Q

What number indicates severe brain injury on the glascow coma scale?

A

anything below an 8

121
Q

cervical lymphnodes

A
  • should be non palpable, if palpable they should be mobile
  • need to get it checked if it is large and nonmobile
122
Q

poterior auricular

A

behind ear

123
Q

occipital

A

near back of head/ occipital lobe

124
Q

deep cervical

A

lower neck

125
Q

superficial cervical

A

lower ear and parotid

126
Q

posterior cervical

A

behind superficial cervical

127
Q

supraclavicular

A

above clavicle

128
Q

preauricular

A

in front of ear

129
Q

parotid

A

below ear

130
Q

submental

A

below chin

131
Q

tonsillar

A

below temporomandibular joint

132
Q

submandibular

A

below mandible

133
Q

presbyopia

A

need reading glasses

134
Q

hyperopia

A

far sighted

135
Q

myopia

A

near sighted

136
Q

pupil accommodation

A

eyes cross, pupils constrict

137
Q

delirium

A

acute, usually occurs because of a disease and usually goes away after recovery

138
Q

dementia

A

onset is usually slow and insidious

139
Q

depression

A

describes a negative change in mood that has persisted for at least two weeks

140
Q

ADLs

A

bathing, eating, walking, toileting, grooming

141
Q

IADLs

A

driving, meal prep, housekeeping, laundry, finances, taking medications

142
Q

diplopia

A

double vision

143
Q

alert

A

awake and easily aroused

144
Q

somnolent

A

abnormally drowsy

145
Q

lethargic

A

not fully alert, drifts off to sleep when not stimulated

146
Q

obtunded

A

sleeps most of the time, difficult to arouse

147
Q

stupor

A

semi coma, unconscious, responds to only persistent and vigorous shaking

148
Q

coma

A

unconscious. no response to pain or any external stimuli

NUR 265 (2 decks)

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