funds test 2 Flashcards

Question

Delirium

Answer 1

Acute confusion, reversible, quick

Answer 2

Person is unable to process or manage intensity or quantity of incoming sensory stimuli; accompanied by feelings of being out of control and overwhelmed

Answer 3

A lessening or lack of meaningful sensory stimuli, monotonous sensory input, or an interference with the processing of information

Answer 4

Measures the intactness of the reflex arc. Stimulus is applied with the reflex hammer to the insertion tendon of the muscle. Use short, snappy blow–the limb should be relaxed and muscle partially stretched 0 –no response 1+–diminished reflex (may be normal) 2+–normal 3+–briskier than normal (may be normal) 4+–hyperactive–upper neuron disorder suspected

Answer 5

C5, C6 Flex patient’s arm at the elbow with their forearm resting on the thigh, palm up. Place your thumb on the base of the biceps tendon in the antecubital fossa. Strike your thumb with the sharp side of the reflex hammer

Answer 6

C7, C8 Have pt’s arm hang loose at a right angle and strike the tricep tendon (just above the olecranon process) with the sharp side of the hammer

Answer 7

Patellar, L2, L3, L4 Client performs Jendrassik maneuver (teeth clenched and arms hooked together) and strike the patellar tendon just below the patella with the flat side of the hammer If patient remains supine, support the back of their knee while the leg is flexed at a 45 degree angle

Answer 8

L5-S2 Have the pt sit at the edge of the examination table with their legs dangling above the floor. Gently dorsiflex the foot at the ankle and position the joint at 90 degrees or until resistance is felt. Strike the achilles tendon with the sharp side of the hammer

Answer 9

High BP, high cholesterol, diabetes, afib, carotid stenosis, atherosclerosis, tobacco use, physical inactivity, obesity, excessive alcohol intake, illegal drug use

Answer 10

Increasing age, gender (male), family history, prior stroke or TIA (transient ischemic attack or “mini stroke”, race (African American, Hispanic, and Asian population at higher risk)

Answer 11

Sudden numbness or weakness of the face, arm, or leg, especially unilateral Sudden trouble speaking or understanding Sudden trouble seeing in one or both eyes Sudden trouble walking, dizziness, or loss of balance or coordination Sudden, severe headache with no known cause FAST– Facial drooping, Arm weakness, Speech difficulties, and Time

Answer 12

Regain balance. Teach patient to maintain balance in a sitting position, then to balance while standing and begin walking as soon as standing balance is achieved. Manage sensory difficulties. Approach patient with a decreased field of vision on the side where visual perception is intact. Visit a speech therapist. Consult with a speech therapist to evaluate gag reflexes and assist in teaching alternate swallowing techniques Repositioning to prevent bed sores and things

Answer 13

Caused by a clot leading to limited blood flow to brain

Answer 14

Caused by rupture of blood vessel in brain

Answer 15

Hemi means side, paresis means paralysis, so hemiparesis means paralysis of one side. Effects legs, arms, and face

Answer 16

Depth perception, ability to identify object by touch

Answer 17

Sensing what is written by touch (someone daws an “8” on your hand and you can identify it)

Answer 18

brain and spinal cord

Answer 19

of cranial nerves, spinal nerves, reflex arc, and ANS (not controlled by you)

Answer 20

To provide objective assessment of consciousness; to alert healthcare personnel of changes in LOC A score of 13-15 indicates mild brain injury 9-12 is moderate 3-8 is severe

Answer 21

4. Spontaneously 3. To speech 2. To pain 1. No response

Answer 22

5. Oriented to time, person, and place 4. Confused 3. Inappropriate response 2. Incomprehensible words 1. No response

Answer 23

6. Obeys command 5. Move to localized pain 4. Flex to withdraw from pain 3. Abnormal flexion 2. Abnormal extension 1. No response

Answer 24

mediastinum (cavities that enclose the lungs) and pleural cavities

Answer 25

3 lobes: superior, lateral, and inferior

Answer 26

2 lobes: superior and inferior, and also contains the cardiac notch, which is where the heart is

Answer 27

Larynx Trachea Bifurcation of the trachea (where it splits into two) Left and right main bronchus Secondary bronchi Tertiary or segmental bronchi Bronchioles

Answer 28

Mouth Nose Pharynx NOL= nasopharynx, oropharynx, and laryngopharynx Trachea (branchial tree) Lobar bronchi Segmental bronchi Bronchioles Alveoli (where gas exchange happens) Lungs

Answer 29

Apex: Retroclavicular: behind the clavicle Base: Bottom, sits on diaphragm

Answer 30

Thin slippery pleurae are serous membranes that form an envelope between the lungs and the chest wall. Visceral: lines the lung tissue, inner layer surrounding lung Parietal: lines the entire lung, most outer layer of the lung Pleurisy: inflammation of the pleura, pain comes from inspiration

Answer 31

Sternum 12 pairs of ribs 12 thoracic vertebrae Diaphragm

Answer 32

Suprasternal notch Sternum Sternal angle Costal angle Upper and middle lobes

Answer 33

Posterior: upper lobes = t1-t4 T4-t12

Answer 34

Observe pattern and effort of respirations Bradypnea: RR below 12 Tachypnea: RR above 20 Biot: Cyclic breathing characterized by shallow breathing alternating with periods of apnea Cheyne-Stokes: Cyclic breathing pattern characterized by periods of respirations of increased rate and depth alternating with periods of apnea Kussmaul: Increased rate and depth of respirations Observe for dyspnea, cyanosis, clubbing, AP diameter (normal vs barrel chest)

Answer 35

Check extent and pattern of thoracic expansion and trachea position Check fremitus (vibrations) for characteristics Symmetric chest expansion Tactile fremitus Have patient say “99” or “blue moon” in order to find the tactile fremitus (it will vibrate) Palpate the chest wall

Answer 36

Detect fluid filled or consolidated portions of the lung

Answer 37

Listen with stethoscope

Answer 38

Hemispheric injury in cerebral cortex Upper extremities at core, plantar flexion (feet inward), very tense Head kind of up towards chest

Answer 39

Lesion in the brain stem at mid or upper pons Head flexed backwards, legs are straight, feet pointed downward, arms are straight and extended, hands are curled

Answer 40

neurological condition characterized by weakness or paralysis and reduced muscle tone without other obvious cause

Answer 41

Deep cough Splinting (deep breathing and coughing together) Stacked cough Low-flow (huff) cough Quad cough

Answer 42

Teaching Deep Breathing and Coughing Pursed-lip breathing: decreases amount of CO2 in blood Chest physiotherapy: pumping chest breaks up congestion, inhale and cough instead of exhale Percussion Vibration Postural drainage Aerosol therapy Aerosol medications Metered-dose inhalers Dry powder inhalers Handheld nebulizers Dyspnea management While pt is sitting down, relaxation techniques, pulmonary rehabilitation Hyperventilation management Assisted ventilation Artificial airways Oral or nasopharyngeal airways Endotracheal tubes (intubation): into mouth Tracheostomy: incision into neck

Answer 43

Thoracic wall becomes more rigid in later decades of life; protective functions of lungs are impaired; normal PaO2 decreases with decreased response to hypercapnia (too much CO2)

Answer 44

Resonance in a normal lung when you do percussion Resonance is when you put your hand over intercostal space or lung tissue tapping on finger to hear sound (low pitched, hollow) Hyperresonance: low pitched, booming sound, too much air Dullness when fluid is present in lung Should hear normal breath sounds instead of adventitious ones

Answer 45

heard over the trachea (high pitch and intensity) inspiration is less than expiration

Answer 46

Heard over major bronchi (moderate pitch and intensity) inspiration = expiration

Answer 47

Heard over healthy lung tissue (low pitch and intensity) inspiration greater than expiration, most commonly heard

Answer 48

Heard in lower lobes Fine crackles sound like hair rubbing together Pulmonary edema or fibrosis Fine: discontinuous, popping, if you cough it doesn’t go away, still hear whether you inhale or exhale Course: loud, low pitched, bubbling and gurgling, found early in patients, heard late in inspiration, pulmonary edema, pulmonary fibrosis Crepitus: crackling sounds

Answer 49

Heard in the upper lobes Gurgling sound Usually clears after coughing

Answer 50

Heard over the trachea Senoras bronchi: low pitched, mostly in expiration, moaning sounds, pts normally have bronchitis with this Sibilant: high pitched sound, musical squeaking wheeze, “vibrating wheeze” air being pushed out, occurs mostly in expiration, asthma or chronic emphysema or some obstruction

Answer 51

Heard at the base Like leather rubbing together

Answer 52

Heard in upper airways Inspiratory vs expiratory Loudness Pitch Location on chest wall Indicates blockage, could be serious or caused by a cold

Answer 53

Patient can walk 1 mile at own pace before experiencing SOB

Answer 54

Patient has SOB after walking 100 yards on level ground or climbing a flight of stairs

Answer 55

The patient has SOB while talking or performing ADLs

Answer 56

The patient has SOB during periods of no activity

Answer 57

The patient has SOB while lying down

Answer 58

Inhale through the tube ONLY, suck in as if you are drinking through a straw

Answer 59

increased resonance of voice sounds heard when auscultating the lungs

Answer 60

abnormal transmission of sounds from the lungs or bronchi

Answer 61

lowest delivery of oxygen room air is 21 ( each liter is an added 3-4%)

Answer 62

changed according to color or dial on tubing

Answer 63

most common O2 delivery device, has a minimum

Answer 64

bag may not be overinflated or deflated, can deliver a nonrebreather mask or reservoir up to 15 L of oxygen, close to 100%

Answer 65

The ability to look at things from another’s perspective.

Answer 66

Underlying assumption is that the person is worthwhile and has value and dignity; avoids unnecessary labeling.

Answer 67

open, direct and sincere

Answer 68

demonstrate to patients, families, significant others that they can rely on nurses without doubt, question, or judgement

Answer 69

Self-awareness and self-reflection: Results in being aware of one’s own personality, values, cultural background, and style of communication; taking responsibility for one’s actions as a professional; and being separate from, but connected to, others

Answer 70

Rescue feelings False reassurance Giving advice Changing the subject Being moralistic Nonprofessional involvement

Answer 71

Conveys information through written word

Answer 72

Conveys information through spoken word

Answer 73

Conveys information through gestures, facial expressions, posture, space, appearance, body movement, touch, voice tone and volume, and rate of speech

Answer 74

Interpretation of communication

Answer 75

Relationships among written, verbal, nonverbal, and/or metacommunication are aligned to give the same “message”

Answer 76

Relationships among written, verbal, nonverbal, and/or metacommunication are contradictory and give a “mixed message”

Answer 77

Offering of Self & Touch Open ended questions Opening remarks Active listening: eye contact, nodding, paying attention Using silence Summarizing Presenting Reality

Answer 78

Restatement Reflection Exploring Encouraging elaboration & Seeking clarification Focusing Giving information & Looking at alternatives

Answer 79

regulates areas of information management, including security of records. If you want to do written assignments, you must de-identify the patient

Answer 80

(protected health information) is data that relates to the health of an individual (past, present, or future). HIPAA protects this data

Answer 81

Admission entries Progress notes Flow sheets MAR Plan of care Critical pathways Written handoff summary Incident report

Answer 82

To identify patient, support diagnosis, justify treatment, document course and results, and promote continuity of care

Answer 83

Should be accurate Documentation should only include observations that nurses have seen, heard, smelled, or felt. Observations or statements made by other professionals need to be identified as such All charted documentation stays, no erasing! Proofread and use correct spelling/medical terminology! Should be concise and complete Partial sentences and phrases should be used in narrative Patient’s name and terms referring to patient can be eliminated in narrative charting Only commonly accepted and institution-approved abbreviations should be used Should be objective Using direct quotes can help maintain objectivity, especially when documenting psychosocial and mental health issues Actual patient behavior should be described rather than making interpretations Organized and timely Information should be documented chronologically and include patient response to interventions Timely documentation decreases the chance of forgetting something important All medications and procedures should be documented upon completion

Answer 84

Subjective, objective, assessment, pain

Answer 85

problem, intervention, evaluation

Answer 86

Focus, data, action, response

Answer 87

competency-based education

Answer 88

Situation, background, assessment, recommendation

Answer 89

Introduction, patient, assessment, situation, safety concerns, (the), background, actions, timing, ownership, next

Answer 90

I am concerned, I am uncomfortable, this is a safety issue

Answer 91

Keeping information private is a legal and an ethical requirement. Applies to written and computerized medical records and any other information pertaining to the patient’s health status or care. The Health Insurance Portability and Accountability Act (HIPAA) regulates all areas of information management, including security of records. Students must de-identify any patient information in written assignments to be HIPAA compliant. Privacy screens, space F4 causes screen to close to prevent nosiness and potential breeches

Answer 92

Observe and compare both sides of body for symmetry Height: Measure for comparison over time (loss of height is common as person age) Posture: head erect – both shoulders and hips at equal heights bilaterally Inspect spine from the side. Note curvatures. Note size and contour of the joint Inspect skin and tissues over the joints for color, swelling and any masses or deformities

Answer 93

Palpate joint bilaterally, including skin for temperature, muscles for tone, bony articulations and area of joint capsule Note any warmth, tenderness, inflammation, edema, stiffness, crepitus, deformities, limitations, and instability Ask for active ROM – if you see a limitation gently attempt passive ROM do not move past point of pain or resistance Functional assessment with limitations in ROM

Answer 94

Decreased muscle strength and tone Lack of coordination: musculoskeletal due to aging or neurological Altered gait: shuffling, unsteadiness Falls: risk increases as you age (anybody is at risk, post-op) Decreased joint flexibility Pain on movement: little movement, refuse medications Activity intolerance

Answer 95

Transfers Lift teams Hydraulic lifts Ceiling lifts Stand-up assist lifts Two- or three-person lifts

Answer 96

Alignment and posture: Alignment is achieved when the joints and muscles are not experiencing extremes in extension or flexion or unusual stress; upright posture and movement require a balanced center of gravity. Balance: Maintaining balance is a complex function of counteracting gravity and coordinating reflexes to maintain posture. Coordinated movement: The cerebellum, cerebral cortex, and basal ganglia are responsible for the control of motor functions. (coordinated smooth movements, only skeletal)

Answer 97

Falls: risk increases as you age (anybody is at risk, post-op) Risk for disuse syndrome (being sedentary) Risk Assessment weakness, fatigue, or distressing symptoms after routine exercise or activities; fall risk. presence of current or chronic health problems that may limit mobility or decrease activity tolerance

Answer 98

Exercise: Exercise that actively requires alignment, posture, balance, and coordinated movement offers physiologic and psychological benefits. Characteristics of movement Full range of motion AoRM Active range of motion (doing it themself) PoRM Passive range of motion (nurse helping) Balanced coordinated gait

Answer 99

Lifestyle and habits: obesity (modifiable, diet) Intact musculoskeletal system (modifiable with trauma and diseases→ diabetics) Nervous system control (excitable) Circulation and oxygenation: not enough oxygen getting to muscle → atrophy (hypertrophy by going to the gym and hydrating) Energy (cluster activity based on energy level, CHF needs long periods of rest) Congenital problems: born with a broken limb or weak muscles Ex: Jerry Lewis: muscular dystrophy (progressive weakness in male children → may need ventilators and NG tubes) Affective disorders Therapeutic modalities

Answer 100

to keep the legs apart or “away” from each other

Answer 101

draw inward, or closer to the body

Answer 102

Flexion of the shoulder or hip is movement of the arm or leg forward

Answer 103

increases the angle and straightens the joint.

Answer 104

Transfers Lift teams Hydraulic lifts Ceiling lifts Stand-up assist lifts Two- or three-person lifts

Answer 105

Use your knees when you bend Raise bed to waist level