Lab Quiz 2 Flashcards
Cataracts
Increased opacity of the lens
One of the most common eye disorders
Cloudy pupils indicate cataracts
Hyperopia
Farsightedness
Rays of light enter the eye and focus behind the retina
People are able to see distant objects but not close ones
Myopia
Nearsightedness
Rays of light enter the eye and focus in front of the retina
People are able to see close objects but not distant objects
Strabismus
Condition in which both eyes do not focus on an object simultaneously
Glaucoma
Increased intraocular pressure
Obstruction of the outflow of aqueous humor causes this
With out treatment this leads to blindness
Retinopathy
Non inflammatory eye disorder resulting from changes in retinal blood vessels
Presbyopia
Impaired near vision in middle age and older adults
Caused by loss of elasticity of the lens
Normal size of the pupil
3 to 7 mm in diameter
How to test pupillary reflexes (light and accommodation)
Ask the patient to look straight ahead bring the penlight from the side of his or her face directing the light into their pupil. It should constrict and the opposite pupil constrict con sensually
Accommodation the patient gazes at a distant object (far wall) and then at a test object (finger or pencil) held 4 inches from the bridge of their nose the pupils should converge and accommodate by constricting when looking at close objects
PERRLA
Use if assessment of pupillary reaction is normal in all test
Pupils equal, round, reactive to light, and accommodation
Normal responses that determine a patients level of consciousness
Responds to questions quickly and expresses ideas logically
Glasgows coma scale
Use when a patient has a lower consciousness. Check to see if the patient has any sensory losses before starting. The higher the score the better the persons neurological function.
Delirium
Is an acute mental disorder that occurs among hospitalized patients most often presents itself within the first 48 to 72 hours of hospital admission. Characterized by Confusion disorientation and restlessness. Often labeled with “sundown syndrome” because patients get worse at night. Condition often reverses when it’s correctly assessed and treated.
Jaundice
Increased deposits of bilirubin in tissues
Yellow orange discoloration
Erythema
Red discoloration can indicate circulatory changes
Often accompanies an increase in temp
Pallor
Decrease in color of skin. Often accompanies a decrease in skin temp and reflects a decrease in blood flow
You can identify stage one of a pressure ulcer by?
Noting warmth over an area of erythema
Turgor
Degree of elasticity of skin
What do edema and dehydration do to turgor?
Diminishes turgor. Skin stays pinched and shows tenting. The person with poor skin turgor does not have resilience to normal wear and tear. Which predisposes the patient to skin breakdown
Petechiae
Non blanching pin point size red or purple spots on skin caused by small hemorrhages in the skin layers.
Edema
Area of skin becomes swollen or edematous from a build up of fluid in the tissues. Skin appears stretched and shiny
Pitting edema
When pressure from an examiners fingers leaves an indentation in the edematous area.
Skin lesions
Refers broadly to any unusual findings of the skins surface
Papule
Circumscribed solid elevation in skin
Atrophy
Thinning of skin with loss of normal skin furrow appears shiny and translucent
Cyanosis
A slightly bluish or grayish discoloration in skin
Vesicle
Circumscribed elevation of skin filled with serous fluid
Pustule
Circumscribed elevation of skin similar to Vesicle but filled with pus
Macule
Flat non palpable change in skin color smaller than 1 cm
Freckle Petechiae
What location should the nurse use to listen for clients apical pulse?
The fifth intercostal at left midclaviular line
The second heart sound (s2) occurs when?
The aortic and pulmonic valves close
The first heart sound (s1) is heard when?
There is rapid ventricular filling
Macular degeneration
Blurred central vision caused by progressive degeneration of the center of the retina
Most common vision impairment of individuals over 50. Most common cause of blindness in older adults there is no cure
Stage 4 pressure ulcer
Ulcer is full thickness tissue loss with exposed bone tendon or muscle. Slough or Eschar may be present. It often includes undermining and tunneling
Stage 3 pressure ulcer
Full thickness skin loss (fat visible) ulcer is full thickness tissue loss subcutaneous fat may be visible but bone or tendon or muscle are not visible. Some slough may be present
Stage 2 pressure ulcer
Partial thickness skin loss or blister. Partial thickness loss of dermis presents as a shallow open ulcer with a red pink wound bed without slough. It may also present as intact or open ruptured serum filled or serosangineous filled blister. Presents shiny or dry shallow ulcer with out slough or bruising
Stage 1 pressure ulcer
Intact skin presents with non blanchable erythema of localized area discoloration of the skin warmth edema hardness or pain may be present. May be difficult to detect in patients with darker skin tones
Braden scale
Is a valid tool used for pressure ulcer risk assessment. Lower total score indicates a higher risk for pressure ulcer development
When assessing pulse strength 2+
Expected normal
Capillary refill is normal if less than
2 seconds
