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final exam Flashcards

(100 cards)

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1
Q

focused exam

A

smaller scope
increased depth for specific issues

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2
Q

comprehensive exam

A

complete health history and physical assessment performed
e.g. an annual sports physical

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3
Q

subjective data

A

all information comes directly from the patient’s mouth

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4
Q

objective data

A

anything that is measurable like vitals

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5
Q

what is the chief complaint?

A

concise statement of the symptoms that caused the patient to seek medical care

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6
Q

what is the review of systems

A

a series of questions about all of the body systems
ask the patient about any symptoms they have

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7
Q

pre-interaction phase

A

what is done before meeting the patient:
look at chart to have an idea about what is going on with the patient

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8
Q

beginning phase

A

close the door
introduce yourself
ask the patient what they want to be called

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9
Q

working phase

A

collect data using open and closed ended questions
avoid asking “why?”
maintain therapeutic communication

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10
Q

closing phase

A

ask if there is anything else the patient needs
summarize everything; care plan

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11
Q

therapeutic communication techniques

A
  1. focus on the patient
  2. self concept
  3. empathy
  4. non-verbal
  5. verbal
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12
Q

modifiable cardiovascular disease risk factors

A

smoking
obesity
high cholesterol
high BP

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13
Q

non-modifiable cardiovascular disease risk factors

A

age
family history
diabetes dx

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14
Q

what happens during systole

A

ventricles contract and eject blood into the lungs & body

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15
Q

during systole what valves are open and what valves are closed

A

mitral & tricuspid valves are closed
aortic & pulmonary valves are open

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16
Q

during diastole what valves are open and what valves are closed

A

mitral & tricuspid are open
aortic & pulmonary valves are closed

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17
Q

______ is twice as long as _____ to allow for the ventricles to fill

A

diastole is twice as long as systole

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18
Q

what is the cause of a murmur

A

heart valve fails to close fully which causes the blood to leak through the valve

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19
Q

where do murmurs originate

A

the heart or great vessels
usually louder over the upper pericardium and quieter closer to the neck

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20
Q

are murmurs systolic or diastolic

A

they can be both

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21
Q

PV normals

A

skin is normal for ethnicity
hair distribution is normal
no lesions or sores
no edema
venous distribution is normal in legs

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22
Q

ineffective peripheral tissue perfusion is caused by ________?

A

decreased O2

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23
Q

ineffective peripheral tissue perfusion characteristics:

A

weak or absent pulses
dry skin
pale skin
prolonged capillary refill

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24
Q

peripheral tissue perfusion nursing interventions

A

assess the dorsalis pedis or posterior tibialis pulses bilaterally, if you can’t feel them use the Doppler, if the Doppler doesn’t pick it up notify the dr

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25
0 pulse meaning
absent
26
1+ pulse meaning
weak and thready
27
2+ pulse meaning
normal pulse
28
3+ pulse meaning
full, increased pulse
29
4+ pulse meaning
bounding pulse
30
PV symptoms of decreased blood flow
skin is cool to the touch, thin, dry, scaly thick toenails pulses are weak, unequal, or absent intermittent claudication occurs
31
abnormal inspection in PV system
clubbing/cyanosis lesions/sores edema varicose veins/spider veins abnormal hair distribution the 7 P's
32
what are the 7 P's
pallor polar pulseless paresthesia paralysis pain perfusion
33
what is something that causes cool body temp
decreased arterial blood supply in the lower extremities
34
what is something that causes poor turgor
dehydration
35
what causes Stemmer sign to be positive
inability to pinch skin on the dorsal hand or foot of the affected extremity
36
african american skin alterations
keloid formation pseudofolliculitis ashy dermatitsis
37
asian skin alterations
less body and facial hair
38
arabic and indian skin alterations
acne ecemza warts fungal skin conditions
39
arabic skin alterations
lesions mongolian spots congenital nevi (moles)
40
where are pressure sores most likely to be found
scapula coccyx heels
41
what are 2 perfusion issues related to the skin
arterial and venous ulcers
42
thorax inspection normal findings
chest is a 2:1 ratio color shape condition of fingernails unlabored RR
43
when palpating the thorax what do you test for
symmetrical chest expansion from the posterior side tactile fremitus trachea placement
44
decreased fremitus means
foreign body
45
increased fremitus means
localized pneumonia
46
wheezing sounds like ________ and is common in_______
sounds like whistling and is common in pt with COPD, asthma, & bronchitis
47
stridor sounds like______ and it is due to_______
sounds like crowing and it is emergent it is due to an airway obstruction
48
rales/crackles sounds like_______ does not ______ is caused by_________
intermittent, cracking, popping does not clear with cough caused by fluid, inflammation, or consolidation of alveoli
49
rhonchi sounds like____ is caused by_____ is cleared with______
sounds like low pitched snoring is caused by secretions going through the airways louder on exhalation than inhalation cleared with cough
50
abnormal abdominal inspection assessment
color (jaundice) visible masses visible pulsations contour
51
abnormal abdominal percussion assessment
pain and dullness over the mass or fluid CVA tendernes-->kidney
52
abnormal abdominal auscultation assessment
absent bowel sounds in each quadrant bruits
53
abnormal abdominal palpation assessment
pain and tenderness enlarged organs guarding palpable masses
54
normal abdominal inspection
abdomen flat and symmetrical no scars, striae, or varicosity skin is even toned no visible pulsations no hernias no distention
55
normal abdominal auscultation
bowel sounds present in all 4 quadrants no bruits, venous hums, or friction rubs
56
normal abdominal percussion
tympany noted over most of the abdomen dullness over the liver no pain with kidney percussion
57
normal abdominal palpation
no pain, masses, guarding, tenderness spleen is not palpable aortic pulsations are palpable and measures 2cm
58
what does a normal bladder scan show
less than 600 mL before voiding less than 200 mL after voiding
59
what is Blumberg sign
rebound tenderness checks for peritonitis press down and lift up quickly: if there is pain then it is positive
60
what does Murphy's sign check for
checks for inflammation of the gallbladder
61
what is the Obturator sign
flex pt right thigh at the hip with the knee bent and rotate the leg internally at the hip if pain occurs then Obturator sign is positive suggesting appendix or peritoneal inflammation
62
flexion
brings bones together by decreasing the angle
63
dorsiflexion
bending the ankle so the toes move up
64
plantar flexion
bending the ankle so the toes move down
65
extension
increases the angle to a straight line e.g. extend leg or arm
66
hyperextension
extension beyond the neutral point
67
abduction
away from the center of the body
68
adduction
towards the center of the body
69
pronation
palm down
70
supination
palm up
71
self-care-deficit
inability to perform ADLs
72
bone mass is related to
race age genetics hormones physical activity calcium intake
73
what are things that increase bone loss
smoking and alc lack of exercise lack of calcium in diet high salt intake
74
what are some muscoskeletal nursing dx
fall risk immobility injury
75
how to prevent osteoporosis
calcium, protein, and vit D weight bearing exercise no smoking and limit alc
76
abnormal heart/neck assessment inspection
jugular vein pressure greater than 3cm
77
abnormal heart/neck assessment palpation
carotid artery 0 or 1+ enlarged heart or displaced PMI chest pain when palpating costochondral junction
78
abnormal heart/neck assessment auscultation
adventitious sounds like: swooshes, rubs, gallops, murmurs abnormal rate/rhythm carotid bruits
79
normal neuro assessment inspection
pt oriented x4 speech is clear and fluent PERRLA symmetrical eye movements
80
DTR 0
no response
81
DTR 1+
diminished, low normal
82
DTR 2+
normal
83
DTR 3+
brisker than normal
84
DTR 4+
very brisk
85
assessing LOC: obtundation
disoriented to time and place
86
assessing LOC: stupor
hard time arousing and very confused when aroused
87
I olfactory
smell
88
II optic
sight; snellen chart
89
III oculomotor
use pen light to assess pupils; pupils should constrict with light; you would document PERRLA if normal
90
IV trochlear
have the patient follow the pen light up, down, side to side, and diagonally
91
V trigeminal
have patient look up and touch the lateral sclera to see if the patient blinks
92
VI abducens
ask patient to follow the pen light through the 6 cardinal fields
93
VII facial
ask patient to smile, frown, raise eye brows, and puff cheeks
94
VIII vestibulocochlear
hearing
95
IX glossopharyngeal
-ask patient to yawn and observe for the upper movement of the soft palate -note ability to swallow -check gag reflex
96
X vagus
ask patient to swallow and speak note any hoarseness
97
XI accessory
ask patient to shrug shoulders against the resistance of the nurse’s hands
98
XII hypoglossal
ask patient to move tongue side to side
99
corneal light reflex aka
Hirschberg test
100
Hirschberg test
Instruct the patient to stare straight ahead at the bridge of your nose. Stand in front of the patient and shine a penlight at the bridge of the patient’s nose. Note where the light reflects on the cornea of each eye​

nu 305 (2 decks)

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