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HAP Final > Last minute freak out > Flashcards

Last minute freak out Flashcards

1
Q

Pulse grading

A

0-3

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2
Q

Normal assessment order

A

Inspect - palpate - percuss - auscultate

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3
Q

Drug Abuse assessment/help

A

Assist - give medical advice
Asses - readiness for change?
Assist - offer help
Arrange - refer to specialists

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4
Q

% of people over the age of 12 who drink

A

52%

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5
Q

% of the 52% who drink who binge drink?

A

23%

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6
Q

% of those who heavily drink

A

7%

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7
Q

Risks from drinking

A
  • Accidents, trauma
  • Cirrhosis
  • Cardiomyopathy, arrhythmias, HTN
  • Cancers of mouth, liver, esophagus
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8
Q

Severe withdrawal alcohol

  • AKA
  • S/S
A

Severe withdrawal = withdrawal delirium

  • Marked autonomic hyperactivity
  • Anxiety, nausea,
  • Increased tremors
  • Vivid hallucinations
  • Life threatening
  • Fever
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9
Q

CIWA scale - Severe withdrawal

A

More than 20

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10
Q

COWS - severe withdrawal

A

More than 36

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11
Q

Alcohol Dependence

A

3 or more of:

  • Can’t stop or attain limits
  • Spent lots of time drinking
  • Spent less time on things that needed to be done
  • Showing tolerance (need more to have effect)
  • Showing signs of withdrawal (tremors, anxiety, sweating)
  • Keep drinking despite problems
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12
Q

At Risk Drinking

A

Binge drinkers who are neither alcohol use disorder or alcohol dependent

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13
Q

Uncomplicated withdrawal

A

-Anxiety
-Tremors
-Hallucinations
-Autonomic hyperactivity (sweat, tachycardic, elevated BP)
Peaks on 2nd day, resolves by 4th or 5th day

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14
Q

Alcohol abuse

A

One or more of:

  • Risk for bodily harm
  • Relationship problems
  • Run ins with the law
  • Role failure
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15
Q

Palpation for heart

A 
Apical pulse 
Carotid Arteries (0-3, 2+ normal)
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16
Q

Binge #s

A

Men: 5 drinks/2hrs
Women: 4 drinks/2 hrs

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17
Q

Risk for drinking when pregnant

A

Fetal alcohol syndrome

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18
Q

Steps for Alcohol Screening/Intervention

A

Ask
Assess
Assist
Follow-Up

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19
Q

ROM Scale

A

0-5

3 - ROM with gravity (can lift but no resistance)

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20
Q

Assess muscles for…

A

Size, tone, strength, sensory, ROM

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21
Q

Normal abdominal/GI sounds with percussion

A

Stomach and intestines: tympany

Liver and spleen: dull

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22
Q

Abnormal GI percussion sounds

A

Dull over fluid, mass, tumor

ascites, feces, tumor

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23
Q

Bowel sound order

A

RLQ - RUQ - LLQ - RLQ

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24
Q

Abdominal bruits indicate

A

Aortic aneurysm
Femoral artery occlusion
Renal artery stenosis

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25
Q

CVA tenderness indicates

A

Kidney inflammation (pyelonephritis)

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26
Q

Order of abdominal assessment

A

Inspection - auscultation - percussion - palpation

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27
Q

Distension

A

Obese - uniformly round with everted umbilicus
Ascites - round with everted umbilicus
Feces or tumor- localized distension

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28
Q

Painful ROM in every direction

A

Inflammation (ex: arthritis)

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29
Q

Painful ROM in one direction

A

ligament, tendon problem

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30
Q

Pronator drift

A

Patient holds arms out with eyes closed
Hold for 10 seconds - negative
If one arm pronates and drifts down - positive for UE weakness

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31
Q

Straight Leg Test

A

aka Lasegue Test

Positive: herniated lumbar disc or nerve irritation

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32
Q

Phalen’s Sign

A

Inverted prayer that tests for carpal tunnel

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33
Q

Tinel’s Sign

A

Tap medial nerve to check for nerve irritation

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34
Q

Confrontation tests CN

A

II - optic

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35
Q

Jaw movement tests CN

A

V - trigeminal

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36
Q

PERRLA tests CN

A

III, IV, VI

Oculomoter, trochlear, abducens

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37
Q

Heaves, lifts, and pulsations may indicate

A

Ventricular hypertrophy
Right side: near sternal border
Left: apex

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38
Q

Graphesthesia

A

Draw number on palm and have pt identify number

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39
Q

Reflex grading

A

0-4

+2 is normal

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40
Q

Clonus

A

Repeated muscular movements (jerking)

41
Q

Plantar Reflex

A

J motion from heel to lateral

Positive: babinski and big toe reflex

42
Q

In babies, babinski is…

A

Normal

43
Q

Hyperreflexia

A

Upper motor neuron injury

44
Q

PMI

A

Point of maximal impulse - 5th intercostal space

45
Q

Top of the heart is called

A

base

46
Q

Bottom of heart is called

A

apex

47
Q

Facial movement tests CN

A

VII - facial

48
Q

Sensory tests on face test CN

A

V - trigeminal

49
Q

Whisper tests tests CN

A

VIII - vestibulochlear

50
Q

Gag reflex tests CNs

A

IX and X - glossopharyngeal, vagus

51
Q

Should shrug tests CN

A

XI - accessory

52
Q

Bruit

A

Low swooshing sound heart with turbulent blood flow, indicating partial occlusion in the artery
-Could indicate atherosclerosis

53
Q

Light tight dynamite tests CN

A

XII - hypoglossal

54
Q

Hyperparesthesia

A

Increased touch sensation

55
Q

Hypoparesthesia

A

Decreased touch sensation

56
Q

Anesthesia

A

No touch sensation

57
Q

Position sense

A

kinesthesia

58
Q

Tests for kinesthesia

A

Move patient’s distal joints and have them identify the direction of movement

59
Q

Stereognosis

A

Place a familiar object in the patient’s hand and have them identify it

60
Q

Which is higher pitched, murmur or bruit?

A

Bruit

61
Q

What do you use to listen to the bruit?

A

Bell

62
Q

JVD distension is

A

abnormal

63
Q

JVD indicates

A

Excess fluid volume

Heart failure

64
Q

Technique to assess JVD

A

Inspect at 45 degrees (head turned slightly)

65
Q

S3

A

Ventricular gallop
Kentucky
Heard after S2

66
Q

S3 indicates

A

Heart failure, fluid overload

67
Q

S3 is normal in

A

children

68
Q

S3 and S4 are what type of sounds?

A

Diastolic

69
Q

S4

A

Atrial gallop
Tennessee
Heard before S1 after S3

70
Q

S4 indicates

A

Ventricular deficiency

Seen with coronary artery disease

71
Q

S4 is normal in

A

older adults

72
Q

S1

A

“Lub”
Beginning of systolic
Closure of AV valves (mitral and tricuspid)
Heard better at base

73
Q

S2

A

“Dub”
End of systolic
Closure of Semilunar valves (pulmonic and aortic)
Heard better at apex

74
Q

Abnormal palpation finding at precordium

A

Thrill

75
Q

Thrill

A

Palpable vibration that signifies turbulent blood flow

76
Q

What should you use to feel thrill?

A

Palm surface of hand

77
Q

what should you use to palpate for temperature on a patient?

A

Dorsal

78
Q

One pulse is

A

Lub Dub

S1, S2

79
Q

Hyporeflexia

A

Lower motor neuron damage

80
Q

Glasgow coma components

A

Verbal response
Best motor response
Eye opening

81
Q

Glasgow - totally unresponsive

A

3 or less

82
Q

Flaccidity

A

Hypotonia

Limp, soft tissue

83
Q

Spascity

A

Hypertonia

Resistant to lengthening

84
Q

Rigidity

A

Constant resistance during passive ROM

85
Q

Hypotonia

A

Flaccidity

86
Q

Hypertonia

A

Spascity

87
Q

FAST

A

Face (droop)
Arms (does one fall?)
Speech (slurred, slow)
Time

88
Q

6 P’s of PAD

A
  • pallor
  • pulselessness
  • paresthesia
  • poikilothermia (cool)
  • paralysis
  • pain
89
Q

Murmurs

A 
Gentle, blowing, swooshing sound that indicates congenital or valve defects 
0-6 on loudness
Quality 
Location 
Duration
90
Q

What can cause murmurs?

A

Exercise, increased blood viscosity, defects

91
Q

When does the heart reach adult size?

A

7 yrs old

92
Q

Is it normal for child to experience SOB when feeding?

A

No

93
Q

Is labored breathing normal in child?

A

Noo

94
Q

One UE edema

A

lymph problem

95
Q

One LE edema

A

DVT

96
Q

Bilateral LE edemas

A

CHF

or Kidney failure/problem

97
Q

Edema grading

A

1 - 4

1: 2 mm, less than 10 seconds
2: 4 mm, 10-15 seconds
3: 6 mm, 1 min or greater
4: 8 mm, 2-5 min

98
Q

Slow cap refill could indicate

A

Low CO, hypothermia, vasoconstriction

99
Q

Thin shiny skin and hair loss in LE

A

malnutrition and arterial insufficiency

HAP Final (5 decks)

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