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NURS 155 > Final exam > Flashcards

Final exam Flashcards

1
Q

the exchange of blood, gases, and fluids between the vessels and tissues and organ systems

A

perfusion

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2
Q
  • Detect a weak peripheral pulse
  • Measure a low blood pressure
  • Magnifies pulsatile sounds
A

Doppler Ultrasonic stethoscope

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3
Q

• Elastic stockings
• Aid in maintaining external pressure on the muscles of lower extremities to promote venous return
• Measure calf for correct size
*prevents edema, fluid pulling down on ankles

A

Thromboembolic device (TED’s)

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4
Q

• Alternately inflates (10-15 sec) and deflates (45-60 sec)
• Decreases venous stasis by increasing venous return through deep veins of the legs
*helps prevent blood clots

A

Sequential compression device (SCD’s)

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5
Q

Which pulses do we check on a regular basis?

A
  • apical
  • radial
  • dorsalis pedis
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6
Q

• Inspect the client’s neck while patient is at a 30-45 degree angle, pt in supine position
*turn head slightly

A

Jugular Venous Distension (JVD)

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7
Q

• Palpate only one at a time to avoid compromising arterial blood to brain
• Auscultate each for the presence
of a bruit

A

carotid artery

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8
Q

blowing, swishing sound indicating blood flow

turbulence. Normally, there is none

A

bruit

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9
Q

What do you inspect of the extremities?

A 
• Color:
Pallor, erythema, cyanotic, mottled
• Moisture: Moist, Dry
• Nail beds: Color, Capillary refill
- normal is <3 seconds
• Temperature: Warm, Cool
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10
Q

4+ on a four-point scale for palpating pulses represents

A

bounding

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11
Q

3+ on a four-point scale for palpating pulses represents

A

full pulse, increased

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12
Q

2+ on a four-point scale for palpating pulses represents

A

expected/normal

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13
Q

1+ on a four-point scale for palpating pulses represents

A

diminished, barely palpable

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14
Q

0 on a four-point scale for palpating pulses represents

A

absent

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15
Q

 first heart sound
 systole
 louder at apex
 coincides with carotid pulse

A

S1-mitral, tricuspid

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16
Q 
 second heart sound
 diastole
 louder at base
• Creates the lub-dub sound
• Note normal rate and rhythm
A

S2- aortic, pulmonic valves

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17
Q

factors affecting respiration include:

A
  • Lifestyle
  • Medications
  • Age
  • Body weight
  • Environment
  • Health status
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18
Q

Ventilation in excess of that required to eliminate carbon dioxide produced by cellular
metabolism

A

hyperventilation

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19
Q

Alveolar ventilation inadequate to meet the body’s oxygen demand or to eliminate sufficient carbon dioxide

A

hypoventilation

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20
Q

Inadequate tissue oxygenation at the cellular level

A

hypoxia

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21
Q

Blue discoloration of the skin and mucous membranes

A

cyanosis

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22
Q

what are the steps in oxygenation?

A
  • ventilation
  • perfusion
  • diffusion
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23
Q

The process of moving gases into and out of the lungs

A

ventilation

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24
Q

The ability of the cardiovascular system to pump oxygenated blood to the tissues and return deoxygenated blood to the lungs

A

perfusion

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25
Q

Exchange of respiratory gases in the alveoli and capillaries

A

diffusion

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26
Q

average respiratory rate for infants?

A

About 30 breaths per minute

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27
Q

average respiratory rate for children (preschoolers)

A

About 25 breaths per minute

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28
Q

average respiratory rate for adults?

A

About 12-20 breaths per minute

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29
Q

Decreased level of oxygen in the blood

A

hypoxemia

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30
Q

Deficiency in amount of oxygen reaching the tissues

A

hypoxia

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31
Q

First signs of hypoxia may include…

A
  • Anxiety
  • Restlessness
  • Confusion
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32
Q

Late sign of hypoxemia and is seen as a

blue tinge to the skin

A

cyanosis

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33
Q

This condition is a chronic condition of oxygen deficiency and is irreversible.

A

clubbing

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34
Q

greater than 24, abnormally rapid

A

tachypnea

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35
Q

less than 10 breaths per minute, abnormally slow

A

bradypnea

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36
Q

lack of respiration for greater than 15 seconds

A

apnea

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37
Q

Abnormally deep, regular, and increased in rate;

A

kussmaul’s

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38
Q

Variable pattern, rate & depth irregular

A

Cheyne-Stokes

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39
Q

Normal breath sounds include?

A
  • bronchial
  • bronchovesicular
  • vesicular
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40
Q

(tracheal) Loud, harsh, hollow, tubular, high pitched breath sound

A

bronchial

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41
Q

(over larger bronchi) Blowing sounds, medium pitched breath sounds

A

bronchovesicular

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42
Q

(peripheral lung fields) Soft, breezy, low pitched breath sounds
• Easy auscultation

A

vesicular

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43
Q
  • a type of adventitious sound, is not pathologic; short, popping, crackling sounds that sounds like fine crackles but do not last beyond a few breaths
  • heard only in periphery and disappear after first few breaths or after a cough
A

atelectatic crackles

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44
Q

(rales) crackling sounds, may be fine, medium, or coarse

A

crackles

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45
Q

high-pitched, musical

A

wheezes

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46
Q

(gurgles) loud low-pitched, coarse, rumbling, during inspiration & expiration

A

rhonchi

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47
Q

dry, grating sounds as the pleural cavity is rubbing against

A

pleural friction rub

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48
Q
  • Delivers 40-70% oxygen
  • Minimum flow rate 6-10L/minute
  • Adjust flow rate so that bag doesn’t collapse
  • Approximately 1/3 of exhaled air goes back into bag
A

partial (non-rebreather)

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49
Q
  • Delivers 60-80% oxygen
  • Has one–way valve that keeps air from entering reservoir bag
  • Adjust liter flow so that reservoir bag does not collapse more than ½ during each inspiration
A

non-breather

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50
Q

Helps prevent atelectasis and sleep apnea.

A

CPAP (Continuous Positive Airway Pressure) and

BiPAP (Bi-level Positive Airway Pressure)

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51
Q

discontinuous abnormal lung sounds include?

A
  • Crackles—fine
  • Crackles—course
  • Atelectatic crackles
  • Pleural friction rub
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52
Q

continuous abnormal breath sounds include

A
  • Wheeze—sibilant
  • Wheeze—sonorous rhonchi
  • Stridor
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53
Q

Disorders caused by which deficiency are among the leading causes of illness and death in the United States

A

nutritional

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54
Q

what nutritional assessments can be performed?

A

Anthropometric Measurements
Biochemical Analysis
Clinical Examination
Dietary Evaluation

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55
Q 
Noninvasive techniques that quantify body dimensions
• Height
• Weight
• Waist, Arm and Head Circumference
• Skin Fold Thickness
A

anthropmetric measurements

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56
Q

Marker of healthy weight to body height

Indicator of malnutrition or obesity

A

Body mass index

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57
Q

Classifications of BMI:

for Underweight – below

A

below 18.5

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58
Q

Classifications of BMI:

for Normal weight –

A

18.5-24.9

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59
Q

Classifications of BMI:

for Overweight

A

25-29.9

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60
Q

Classifications of BMI:

for Obesity –

A

BMI of 30 or greater

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61
Q

Indicates skeletal muscle mass and fat
stores
Measure in Centimeters
Compare measurement with standards

A

circumference

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62
Q

what factors influence nutrition?

A 
Nitrogen balance
Hospitalization
Physical problems or limitations
Limited fixed incomes
Medications
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63
Q

What are the causes of distention (5 F’s)?

A 
5 F’s
• Fat
• Fluid
• Flatus
• Fetus
• Fibroids
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64
Q

the physical and chemical processes by which the body builds and maintains itself through anabolism and
catabolism

A

metabolism

65
Q

hypothyroididm leads to a decrease in?

A

appetite

66
Q

hyperthyroidism leads to an increase?

A

appetite

67
Q

weak, shakey, hungry, jittery, sweaty. – late confusion,

seizures

A

hypoglycemia

68
Q

– polyuria, thirst, drowsiness, also hungry, Fruity

breath

A

hyperglycemia

69
Q

the removal of fluids and wastes from the body
Bowel
Urinary

A

elimination

70
Q

1-2 sounds within 2 minutes

A

hypoactive bowel sounds

71
Q

• 5-6 sounds heard in less than 30 seconds

A

hyperactive bowel sounds

72
Q

a rumbling or gurgling noise made by the movement of fluid and gas in the intestines.

A

borborygmi

73
Q

dull percussion can include?

A
  • Mass
  • Bone
  • Enlarged liver
  • Distended bladder
  • Ascites (lateral)
74
Q

tympany percussion can include?

A
  • Air = Gas
  • Air = Distention
  • Air = Pregnancy
  • Ascites (medial)
75
Q

indicate excessive air in the chest

A

tympany

76
Q

sounds heard over solid areas like bone

A

dull

77
Q

labs related to GI elimination include

A

 Total bilirubin:
 Alkaline phosphatase:
 Amylase:
 Carcinoembryonic antigen (CEA):

78
Q

total bilirubin should be

A

0.3-1mg/dl

79
Q

alkaline phosphatase should be

A

30-120 units/dl

80
Q

amylase labs should be

A

60-120 somogyi units/dl

81
Q

carcinoembryonic antigen (CEA) labs should be

A

<5ng/ml

82
Q
  • “a state of complete physical, mental, social well-being, not merely the absence of disease or infirmity” (WHO, 1948)
  • Individual variability
  • A dynamic state of being in which the developmental and behavioral potential is realized to the fullest extent possible (ANA, 1980)
  • Not just the absence of illness.
A

health

83
Q

The process of equipping people to have control over, and to improve physical, emotional, and social health.

A

health promotion

84
Q

A way of life- a life style you design to achieve your highest level of potential for well-being
A process- a developing awareness that there is no end point, but that health and happiness are possible in each moment here and now.
Loving acceptance of yourself
A dynamic balance of physical, psychological, social, and spiritual aspects of a person’s life

A

wellness

85
Q

the components of health & wellness include

A
  • The ability to perform at one’s best
  • The ability to adapt
  • A reported feeling of “being well”
  • A feeling that everything is together and harmonious
86
Q

what are the components of health promotion?

A
  • self responsibility
  • stress reduction and managements
  • physical fitness
  • nutritional awareness
87
Q

internal variable factors influencing health

A

Biological
Psychological
Cognitive
Spiritual

88
Q

external variable factors influencing health

A

Environment
Cultural beliefs
Standards of Living
Social support networks

89
Q
  • Looks at the relationship between a person’s beliefs and behaviors.
  • Predicts how patients will behave in relation to their health and how they will comply with health care therapies.
  • The likelihood that a person will take the recommended preventive health action depends on the perceived benefits of the action minus the perceived barriers to the action.
A

health belief model

90
Q

■ Describes the multidimensional nature of persons as
they interact within their environment to pursue health.
■ A persons unique characteristics and experiences have an impact on their actions and motivation to pursue health promoting behaviors.

A

pender’s health promotion model

91
Q

• Incorporates the interaction of mind, body, and spirit into care
• Holistic Strategies:
Music therapy, relaxation therapy, therapeutic touch, massage, guided imagery, meditation and prayer.
Complementary and Alternative medicines (CAM therapy) play a role.

A

holistic health model

92
Q

provide basics: feeding, IV, rest, medications, oxygen,

etc.

A

Physiological Needs

93
Q

side rails, assist OOB, call bell in reach, assist with

needs of security

A

Safety & Security –

94
Q

develop a therapeutic rapport, include family,

encourage peers and visitors

A

Love & belonging

95
Q

allow control, offer choices, accept client values

A

Self-esteem

96
Q

adult learner principles, active listening style

A

Self-Actualization

97
Q

activities are intended to motivate a person
toward the goal of a higher level of health and wellness
*passive
*active strategies

A

health promotion activities

98
Q

obtain benefit through the intervention of others.
• Government interventions
• Primary health care

A

passive strategies

99
Q

actively seek out and adopt
• Regular exercise and fitness
activities

A

active strategies

100
Q

active changes include?

A
  • Weight reduction
  • Smoking cessation
  • Nutrition
  • Exercise
101
Q

passive changes include?

A
  • Fortified milks and cereals
  • Fluoride in drinking water
  • Trans fat bans
  • GMO debates
102
Q

what are the stages of change?

A

a. Pre-contemplation
b. Contemplation
c. Preparation
d. Action
e. Maintenance

103
Q

no intention to take action in next 6 months

A

pre-contemplation

104
Q

intends to take action in next 6 months

A

contemplation

105
Q

intends to take action within next 30 days

A

preparation

106
Q

has changed overt behavior for less than 6 months

A

action

107
Q

has changed overt behavior for more than 6 months

A

maintenance

108
Q

what are the four broad goals for healthy people 2020?

A
  • Increase quality and years of healthy life
  • Eliminate health disparities
  • Create environments that promote health
  • Promote healthy behaviors
109
Q

a group of diverse medical and health care systems,

practices, and products that are not generally considered part of conventional medicine

A

a group of complementary and alternative medicine

110
Q

what is the leading cause of death in adolescents?

A

accidents

111
Q

what is the leading cause of death in young adults?

A

violence

112
Q

what are the common problems seen in middle aged adults?

A

anxiety and depression

113
Q

increased lumbar curvature-arched back

A

lordosis

114
Q

hunchback-exaggeration of posterior curvature of thoracic spine

A

kyphosis

115
Q

lateral spinal curvature

A

scoliosis

116
Q

patient can perform ROM on their own

A

active ROM

117
Q

you completely do the ROM activities for the patient

A

passive ROM

118
Q

The patient stands with unilateral weakness on the affected side, arm flexed, adducted and internally rotated

A

hemiplegic gait

119
Q

typically defined as the presence of abnormal, uncoordinated movements

A

ataxic gait

120
Q

Encompasses all the functions cells carry out to
maintain homeostasis, in particular their responses
to extracellular signals & how they produce an
intracellular response

A

cellular regulation

121
Q

what are the leading causes of death for men?

A

lung, prostate, and colorectal

122
Q

what are the leading causes of death for women?

A

lung, breast, and colorectal

123
Q

secondary prevention for women include?

A 
• Breast self awareness
• Breast self exam (BSE)
• Clinical breast exam
(CBE)
• Mammograms
• Pap smears
124
Q

secondary prevention for men include?

A
  • Prostate exam

* Testicular exam

125
Q

mammograms should start after what age?

A

40

126
Q

most common cancer in men?

A

prostate/testicular cancer

127
Q

Additional diagnostic tests and screenings for

both men and women include:

A
  • Sigmoidoscopy
  • Colonoscopy
  • Skin Survey
128
Q

Carcinoembryonic antigen is a good indicator for which types of cancer?

A

breast, lung, liver, pancreas, stomach, ovaries, and thyroid cancer

129
Q

Cancer antigen 125 is a good early indicator for which type of cancer?

A

ovarian

130
Q

Neutralize, eliminate, or destroy invaders to our internal

environment

A

immune response

131
Q

the processes by which the nervous system

activates, coordinates and controls the functions of the body

A

neural regulation

132
Q

what is anisocoria?

A

unequal pupills

133
Q

15/15 on the glasgow coma scale indicates?

A

fully alert and normal

134
Q

score of 7/15 or less on the glasgow coma scale reflects?

A

coma

135
Q

the worst score possible on the glasgow coma scale is?

A

3/15

136
Q

drifts off to sleep when not stimulated; arousable but looks drowsy; responds appropriately but slowly; loses train of though

A

lethargic

137
Q

difficult to arouse (needs loud shout or shake); confused when aroused; monosyllable answers; mumbles; constant stimulation
needed

A

obtunded

138
Q

spontaneously unconscious; responds to persistent, vigorous shake or pain; appropriate motor response; only groans or moves restlessly; reflexes intact

A

stupor

139
Q

unconscious; no response to stimuli; no purposeful movement

A

coma

140
Q

dulled cognition; impaired alertness;

disoriented, may hallucinate; often agitated

A

acute confusional state (delirium)

141
Q

Tandem walking is?

A

heel to toe

142
Q

stand up with feet together and arms at sides; close eyes and hold position; wait 20 seconds; slight sway normal

A

romberg test

143
Q

decreased pain sensation

A

hypoalgesia

144
Q

absent pain sensation

A

analgesia

145
Q

increased pain sensation

A

hyperalgesia

146
Q

partial or incomplete paralysis (weakness)

A

paresis

147
Q

loss of motor function

A

paralysis

148
Q

inability to control ROM of muscles (incoordination)

A

dysmetria

149
Q

abnormal sensation (numbness, tingling)

A

parethesia

150
Q

difficulty forming words

A

Dysarthria

151
Q

difficulty with language comprehension or expression

A

dysphasia

152
Q

a quivering movement of the eye.

A

nystagmus

153
Q

measures the percentage of whole blood

that is made up of red blood cells.

A

hematocrit

154
Q

is produced as a product of protein metabolism and excreted through the kidneys.

A

Blood Urea Nitrogen (BUN)

155
Q

urine becomes more concentrated as body tries to compensate for fluid losses. Normal urine specific gravity is 1.003-1.030

A

Urine specific gravity and osmolality

156
Q

Plasma protein which helps hold the intravascular volume in the vascular space.

A

Serum Albumin(3.5-5.5g/dL)

157
Q

•  rate
•  depth
• When accompanied by acidosis (Kussmaul
breathing) – deep and rapid

A

fluid deficit

158
Q 
•  rate
• shallow respirations
• dyspnea increases with
exertion or in the supine
position
• moist crackles present on
auscultation
A

fluid excess

NURS 155 (2 decks)

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