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nu 305 > final exam > Flashcards

final exam Flashcards

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
Q

0 pulse meaning

A

absent

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26
Q

1+ pulse meaning

A

weak and thready

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27
Q

2+ pulse meaning

A

normal pulse

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28
Q

3+ pulse meaning

A

full, increased pulse

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29
Q

4+ pulse meaning

A

bounding pulse

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30
Q

PV symptoms of decreased blood flow

A

skin is cool to the touch, thin, dry, scaly
thick toenails
pulses are weak, unequal, or absent
intermittent claudication occurs

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31
Q

abnormal inspection in PV system

A

clubbing/cyanosis
lesions/sores
edema
varicose veins/spider veins
abnormal hair distribution
the 7 P’s

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32
Q

what are the 7 P’s

A

pallor
polar
pulseless
paresthesia
paralysis
pain
perfusion

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33
Q

what is something that causes cool body temp

A

decreased arterial blood supply in the lower extremities

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34
Q

what is something that causes poor turgor

A

dehydration

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35
Q

what causes Stemmer sign to be positive

A

inability to pinch skin on the dorsal hand or foot of the affected extremity

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36
Q

african american skin alterations

A

keloid formation
pseudofolliculitis
ashy dermatitsis

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37
Q

asian skin alterations

A

less body and facial hair

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38
Q

arabic and indian skin alterations

A

acne
ecemza
warts
fungal skin conditions

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39
Q

arabic skin alterations

A

lesions
mongolian spots
congenital nevi (moles)

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40
Q

where are pressure sores most likely to be found

A

scapula
coccyx
heels

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41
Q

what are 2 perfusion issues related to the skin

A

arterial and venous ulcers

42
Q

thorax inspection normal findings

A

chest is a 2:1 ratio
color
shape
condition of fingernails
unlabored RR

43
Q

when palpating the thorax what do you test for

A

symmetrical chest expansion from the posterior side
tactile fremitus
trachea placement

44
Q

decreased fremitus means

A

foreign body

45
Q

increased fremitus means

A

localized pneumonia

46
Q

wheezing sounds like ________ and is common in_______

A

sounds like whistling and is common in pt with COPD, asthma, & bronchitis

47
Q

stridor sounds like______ and it is due to_______

A

sounds like crowing and it is emergent it is due to an airway obstruction

48
Q

rales/crackles sounds like_______
does not ______
is caused by_________

A

intermittent, cracking, popping
does not clear with cough
caused by fluid, inflammation, or consolidation of alveoli

49
Q

rhonchi sounds like____
is caused by_____
is cleared with______

A

sounds like low pitched snoring
is caused by secretions going through the airways
louder on exhalation than inhalation
cleared with cough

50
Q

abnormal abdominal inspection assessment

A

color (jaundice)
visible masses
visible pulsations
contour

51
Q

abnormal abdominal percussion assessment

A

pain and dullness over the mass or fluid
CVA tendernes–>kidney

52
Q

abnormal abdominal auscultation assessment

A

absent bowel sounds in each quadrant
bruits

53
Q

abnormal abdominal palpation assessment

A

pain and tenderness
enlarged organs
guarding
palpable masses

54
Q

normal abdominal inspection

A

abdomen flat and symmetrical
no scars, striae, or varicosity
skin is even toned
no visible pulsations
no hernias
no distention

55
Q

normal abdominal auscultation

A

bowel sounds present in all 4 quadrants
no bruits, venous hums, or friction rubs

56
Q

normal abdominal percussion

A

tympany noted over most of the abdomen
dullness over the liver
no pain with kidney percussion

57
Q

normal abdominal palpation

A

no pain, masses, guarding, tenderness
spleen is not palpable
aortic pulsations are palpable and measures 2cm

58
Q

what does a normal bladder scan show

A

less than 600 mL before voiding
less than 200 mL after voiding

59
Q

what is Blumberg sign

A

rebound tenderness
checks for peritonitis
press down and lift up quickly: if there is pain then it is positive

60
Q

what does Murphy’s sign check for

A

checks for inflammation of the gallbladder

61
Q

what is the Obturator sign

A

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
Q

flexion

A

brings bones together by decreasing the angle

63
Q

dorsiflexion

A

bending the ankle so the toes move up

64
Q

plantar flexion

A

bending the ankle so the toes move down

65
Q

extension

A

increases the angle to a straight line
e.g. extend leg or arm

66
Q

hyperextension

A

extension beyond the neutral point

67
Q

abduction

A

away from the center of the body

68
Q

adduction

A

towards the center of the body

69
Q

pronation

A

palm down

70
Q

supination

A

palm up

71
Q

self-care-deficit

A

inability to perform ADLs

72
Q

bone mass is related to

A

race
age
genetics
hormones
physical activity
calcium intake

73
Q

what are things that increase bone loss

A

smoking and alc
lack of exercise
lack of calcium in diet
high salt intake

74
Q

what are some muscoskeletal nursing dx

A

fall risk
immobility
injury

75
Q

how to prevent osteoporosis

A

calcium, protein, and vit D
weight bearing exercise
no smoking and limit alc

76
Q

abnormal heart/neck assessment inspection

A

jugular vein pressure greater than 3cm

77
Q

abnormal heart/neck assessment palpation

A

carotid artery 0 or 1+
enlarged heart or displaced PMI
chest pain when palpating costochondral junction

78
Q

abnormal heart/neck assessment auscultation

A

adventitious sounds like: swooshes, rubs, gallops, murmurs
abnormal rate/rhythm
carotid bruits

79
Q

normal neuro assessment inspection

A

pt oriented x4
speech is clear and fluent
PERRLA
symmetrical eye movements

80
Q

DTR 0

A

no response

81
Q

DTR 1+

A

diminished, low normal

82
Q

DTR 2+

A

normal

83
Q

DTR 3+

A

brisker than normal

84
Q

DTR 4+

A

very brisk

85
Q

assessing LOC: obtundation

A

disoriented to time and place

86
Q

assessing LOC: stupor

A

hard time arousing and very confused when aroused

87
Q

I olfactory

A

smell

88
Q

II optic

A

sight; snellen chart

89
Q

III oculomotor

A

use pen light to assess pupils; pupils should constrict with light; you would document PERRLA if normal

90
Q

IV trochlear

A

have the patient follow the pen light up, down, side to side, and diagonally

91
Q

V trigeminal

A

have patient look up and touch the lateral sclera to see if the patient blinks

92
Q

VI abducens

A

ask patient to follow the pen light through the 6 cardinal fields

93
Q

VII facial

A

ask patient to smile, frown, raise eye brows, and puff cheeks

94
Q

VIII vestibulocochlear

A

hearing

95
Q

IX glossopharyngeal

A

-ask patient to yawn and observe for the upper movement of the soft palate
-note ability to swallow
-check gag reflex

96
Q

X vagus

A

ask patient to swallow and speak note any hoarseness

97
Q

XI accessory

A

ask patient to shrug shoulders against the resistance of the nurse’s hands

98
Q

XII hypoglossal

A

ask patient to move tongue side to side

99
Q

corneal light reflex aka

A

Hirschberg test

100
Q

Hirschberg test

A

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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