MIDTERM Flashcards
1
Q
normal rage for pulse
A
60-100 bpm
2
Q
normal range of respirations
A
12-20 breaths per minute
3
Q
normal bp ranges with systolic and diastolic
A
systolic: 120-139
diastolic: 80-89
4
Q
normal range for temperature
A
36-38
5
Q
normal range for SpO2 (pulse oximeter)
A
95-100% or 92-100%
6
Q
what is the range for Temperature and what does it measure
A
normal: 36-38
oral and tympanic: 37
rectal: 37.5
axillary: 36.5
measures the heat production and heat loss in the body’s core controlled by the hypothalamus
7
Q
what is hypothermia?
A
body temp below normal 36
8
Q
what is hyperthermia?
A
hyperthermia is high temperature, above 38
9
Q
what does pulse oximeter measure
A
measures arterial blood (oxygenated blood) that’s attached to the hemoglobin
10
Q
what is hypertension?
A
high blood pressure anything above 140/90
11
Q
what is hypotension
A
low blood pressure anything below 90/60
12
Q
what does blood pressure measure
A
force/pressure hitting against the arterial wall
13
Q
when ventricles relax is called
a. systolic
b. diastolic
A
diastolic
14
Q
when the heart contracts and pushes blood into the body
a. systolic
b. diastolic
A
systolic
15
Q
what is measured when assessing respiration
A
ventilation process of inhaling and exhaling controlled by the medulla oblongata and the chemoreceptors that monitor the co2 and o2
16
Q
what is assessed when checking pulse
A
measures the circulatory system and the electrical impulses sent from the SA node the body’s pace maker felt at different points in the body
17
Q
what are the different pulse points starting from the head down
A
- temporal
- carotid (on the neck below the jawline)
- apical (between the 4th or 5th intercostal space nipple line)
- brachial (ringer finger up or inner arm side)
- radial (on wrist at thumb side)
- ulnar (on wrist on pinky side)
- femoral
- popliteal (behind the knee)
- dorsalis pedis (foot pulse)
- posterior tibial (foot pulse)
18
Q
what is this…
proof that care was given, and in court can be used as a legal document
a. documentation
b. admission charts
c. care plans
A
A,
19
Q
when does one chart..
a. before care
b. immediately after care
c. before, during, and after care
A
B
20
Q
other nurses can document for each other if one nurse is running behind and needs help?
true or false
A
False, you should only ever document for yourself never for others.
21
Q
how do you correct a documentation error?
a. tell the charge nurse you made a mistake
b. white out the area and continue writing over the area to fix your mistake
c. draw a line through and writer error beside it, write initials and date, write correct entry
A
C
22
Q
what is a EHR?
A
electronic health record
23
Q
what is EMR?
A
electronic medical record
24
Q
life time documentation of a person is..
a. EHR
b. EMR
A
A, lifetime record of all health care encounters
25
A single visit/ encounter to the hospital or clinic
a. EHR
b. EMR
B
26
who has access to a patients charts
a. members of the patients health care team who are directly involved
b. health care staff
c. anyone
A
27
what is done through oral, written, audio recorded exchanges?
a. conversations
b. documentation
c. reports
C, for stuff like shift report or transfer report
28
an arrangement for services by another care provider
a. consultation
b. referral
c. report
B
29
consultation is asking for guidance from another member of the health care team
a. consultation
b. referral
c. report
A
30
what are the 6 guidelines for documentation
1. factual
2. accurate
3. complete
4. current
5. organized
6. with BCCNM standards
31
what is the story-like format used in documentation called
narrative
32
SOAP (subjective-objective-assessment-planning_
SOAPIE (subjective-objective-assessment-planning-intervention-evaluation)
PIE (problem-intervention-evaluation)
DAR (data-action-response)
are all methods of recording what
a. progress notes
b. care plan
c. database
A
33
where members from the patients care team have their own section to document is called
a. problem oriented medical record (POMR)
b. charting by exception
c. source records (sections)
C
34
what method of documentation includes
database
problem list
care plan
progress notes
(POMR)- problem oriented medical record
35
patient meets all care standards unless documented
is what type of documentation style
charting by exception, focuses more on documenting the abnormal
36
involves the health care team (interdisciplinary team) in the care plans and management
case management and critical pathways
37
low oxygen in the tissue is called what
hypoxia
38
low oxygen in the blood is called what
hypoxemia
39
heart rate above 100 is called what
tachycardia
40
respirations above 20 is called what
tachypnea
41
heart rate below 60 is called what
bradycardia
42
respirations below 12 are called what
bradypnea
43
when do you measure vital signs
- when patient voices any changes
- during admission or discharge
- before and after medications
- after a fall
- before, after, and during nursing interventions
44
what is the balance between the heat produced and heat lost in the body called?
thermoregulation
45
what happens when the body experiences diaphoresis (excessive sweating), radiation, convection, conduction, evaporation
heat loss
46
- eating or dinking 30 mins before
- circadian rhythm
- environment
- age and hormone levels like in women menopause
- neurological conditions affecting the hypothalamus
- fever (pyrexia)
are all factors that will increase what
a. blood pressure
b. temperature
c. heart rate
B
47
a bacteria that causes a raise in body temperature is called
a. infection
b. pathogen
c. pyrogen
C
48
afebrile means
absence of fever (no fever present)
49
what is the fifth non-official vital sign
a. patients voiced concerns
b. pain
c. nasal temp
pain
50
when you sweat a lot and lose electrolytes
heat exhaustion
51
prolonged exposure to the sun causing hot dry skin and people who experience this do not sweat
heatstroke
52
ice crystals form inside the cells causing...
a. frostbite
b. heat stroke
A
53
what NI can you take if one is feeling hyperthermic
- antipyretics (reduce fevers)
- change their environment to a cool setting
- reduce layers
- cold compress
54
amount of blood the heart pumps in one minute
a. stroke volume
b. cardiac output
B
55
amount of blood pumped out of the left ventricle (left ventricle is where aorta is, meaning it foes to the rest of the body)
a. stroke volume
b. cardiac output
A
56
when documenting VS or pulse and respirations what factors do you NEED to include
rate: numerical value
rhythm: regular/irregular
strength: strong, weak, thready, bounding, diminished
equality: bilaterally
57
The nurse notices that an 18-year-old male has an irregular pulse. What would be the nurse’s best course of action?
A. Read the history and physical of the patient.
B. Assess the apical pulse rate for one full minute.
C. Auscultate for the strength and depth of the pulse.
D. Ask the patient if he feels any palpations.
B, when in doubt check the apical (holly grail of all pulse sites)
58
- caffeine
- exercise
- medications
- emotions like fear, stress, pain
- health conditions conditions
are all factors that increase what VS
factors that affect pulse
59
abnormal rhythm of the heart means..
a. dysrhythmia
b. heart failure
A
60
a normal range for SpO2 for a pt with COPD would be
85-89%, don't go above 92% oxygen because risk of over oxygenating the person
anything below 85% is red flags
61
you would avoid checking SpO2 on the fingers when patient is...and what other sites can you check
cyanotic
acrylics on or nail polish
cold
fidgety
confused
other sites include
- toes
- earlobes
62
- smoking
- body position like laying and hunched over
- exercise
- emotions like anxiety increase breathing
are all factors that affect what VS?
respirations
63
- smoking will increase
- emotions like stress will increase
- medications like antihypertensive's will lower
- daily variations (body's 24hr clock) circadian rhythm in mornings and evening VS usually low bc your just starting off your day, midday VS could be higher bc of the activity
these factors affect what VS?
blood pressure
64
what is orthostatic or postural hypotension?
it's when blood pressure drops when changing positions from laying to standing
65
When assessing the BP of a school-age child, using a
normal-size adult cuff will affect the reading and produce a(n) _______ value.
A. Accurate
B. Indistinct
C. Falsely low
D. Falsely high
C
66
antihypertensive medications
- beta blockers - ending in olol
- calcium channel blockers
- diuretics
- ACE inhibitors -ending in pril
- ARB's (angiotensin receptor blockers) - ending in sartan
67
What are the 2 common types of medication classification used to treat clients with COPD?
bronchodilators
corticosteroids
68
How does a pacemaker work?
only when needed If your heartbeat is too slow (bradycardia), pacemaker sends electrical signals to your heart to correct the beat body's natural pacemaker is the SA node
69
what is the medication that is the first line drug in treatment for HTN and heart failure
- blocks angiotensin I from turning into angiotensin II
- has side affect of non-productive cough (no sputum)
ACE inhibitors
70
what medication blocks calcium giving the heart time to relax and function with ease
calcium channel blockers
71
true or false
women are more likely to live in a communal setting like care home
true
72
According to a 2018 Canadian Community Health Survey, which of the following is true about adults 65 years and older?
A. Female seniors aged 75-84: 43% were living with a partner and owned their dwelling.
B. Female seniors aged 85 or over: 23% lived with children, relatives and nonrelatives.
C. Living with others is beneficial for healthy aging.
D. More woman than men lived alone and rented their dwelling.
D
73
According to a 2018 Canadian Community Health Survey, which of the following is true about adults 65 years and older?
A. Woman have a greater life expectancy compared to opposite-sex partners.
B. Most-used services for seniors: senior centers, homemaker services and transportation services.
C. Living alone was associated with poorer perceived health and social well-being among seniors.
C
74
what is agism
discriminating against ones age
75
True or False:
Most older adults live in nursing homes.
false only a small percent do
76
24 hour supervised nursing care for people who can't care for themselves and perform their own ADL's
a. personal care home
b. Long term care
B
77
older adults live independently but are provided with extra support like lawn mowing
a. personal care home
b. Long term care
A
78
what age related system is this
- loss of skin elasticity, fat loss in extremities
- hair loss
- slower nail growth
- wrinkles present because of reduced collagen
- more spots and lesions present because skin is more sensitive to sun
integumentary
79
what age related system is this
- decreased cilia
- decreased cough reflex
- less flexible chest wall
- higher chance of respiratory infections (due to the decreased cilia)
- increase demand of oxygen with certain activity like walking or stress
respiratory
80
what age related system is this
- blood vessels thickened
- weaker pulse in lower extremities
- colder lower extremities due to the lack of blood flow
- heart valves become stiffer
cardiovascular
81
what age related system is this
- gum bone loss and increase gum disease if not flossing
- reduced saliva (because older people never drink water)
- decreased villi
- peristalsis slows down meaning food moves slower and bowel movements
gastrointestinal
82
what age related system is this
- women have less sphincter tone meaning leakage can happen do Kegel exercises
- men; enlarged prostates meaning compressed urethra meaning harder to pee
- we lose 50% of our nephrons which help filter the waste
- lack of blood flow in the kidneys, meaning they don't function as well as they should
genitorurinary
83
- dehydration causes vertebral disks to thin causing reduced height
- weaker bone mass and bone strength
- increase in wear and tear causing osteoarthritis
what age related system is this
musculoskeletal
84
- decrease in brain weight and size
- dendrites "wear out" affecting memory, reaction time, and learning
- loss of tactile senses (bc of never ending loss)
neurological
85
What is the primary cause of age-related hearing loss (presbycusis)?
A. Infections in the inner ear
B. Damage to the auditory nerve
C. Prolonged exposure to loud noises
D. Degeneration of hair cells in the cochlea
D, the little hairs create sound and friction from losing them hearing decreases
86
difficulty hearing high pitched noises is called
a. presbycusis
b. presbyopia
A
87
not being able to focus on near by objects
a. presbycusis
b. presbyopia
B
88
abnormal bone remodeling of middle ear
a. presbycusis
b. otosclerosis
c. cerumen
B
89
(snapshot of pts status) Codes, allergies, contact information, admitting diagnosis, brief history, ADL's, upcoming tests, mobility level
a. care plan
b. ADL
c. kardex
C
90
a sugar that gives your body a quick fuel and energy
a. complex carbohydrates
b. saccharides
c. simple carbohydrates
C
91
breaks down over time giving the body more energy and slower fuel keeping you full for longer
a. complex carbohydrates
b. saccharides
c. simple carbohydrates
A
92
what is essential in maintaining, repairing and making body tissue.
a. protein
b. water
c. collagen
A
93
what insulin can be given SUB-Q and through IV?
a. Lantus (glargine)
b. humalog (lispro)
c. Humulin R (regular)
C
94
what insulin has a cloudy appearance?
a. Levemir (detemir)
b. Humulin N (NPH)
c. Humulin R (regular)
B
95
True or false:
Medications that lower body temperature are called Antipyretics
true
96
True or false:
Corticosteroids are meds that lowers inflammation in the body and can help breathing problems
true
97
When looking after a confused older adult in care, what is the BIGGEST concern in Acute
care?
a. Conflict with other residents
b. Meal preferences
c. Falls
C
98
True or false:
Albuterol is a medication that causes bronchodilation by acting on the Beta 2 (pulmonary) receptors.
true: beta 1 target the heart, beta 2 target the lungs
99
True or false:
"Young" older adults range from 65-75 years old
false
100
True or false:
Agonists are molecules that bind to and produce an effect within a cell
true
101
True or false:
Damage to the Eardrum or middle ear bones affecting sound to the inner ear is called Conductive Hearing Loss
true
102
True or false:
Vasopressors are meds that contract blood vessels and raise blood pressure.
true
103
True or false:
Metform helps Type 2 diabetics manage blood sugars by increasing cell sensitivity to insulin
true
104
True or false:
Hair cell breakdown in the inner ear prevent sound signal transmission is called Sensorineural Hearing Loss
true
105
When do diabetics take medication to lower blood sugar?
Before meals or in the morning
106
True or false:
Heatstroke is a life threatening condition
true
107
True or false:
Medications that lower blood pressure are called Antihypertensive
true
108
True or false:
Insulin deficiency causes free fatty acids to be used for energy-triggers liver to convert fatty acids into cholesterol
True
109
True or false:
Ventilation is the movement of air between outside environment and lungs.
true
110
True or false:
Vision changes with age is called Presbyopia
true
111
True or false:
High pitched sounds are typically lost with age related hearing impairment
true
112
True or false:
Sliding Scales for Insulin administration are typically used for STABLE diabetics
False
113
True or false:
Hypertension can start with a BP > 140/90
True
114
True or false:
HGBA1C is a lab test that provides an average Blood Sugar level for the patient's last 3 months
True
115
Which symptom is NOT a Hypertensive sign/symptom?
a. Flushed face
b. Headache
c. Nosebleed
d. Diarrhea
D
116
True or false:
It is normal for older adults to have disease as they age.
False
117
What is used to treat a hypoglycemic episode when patient isn’t oriented or swallow
Glucagon kit
118
True or false:
Antagonists are molecules that bind to a receptor, but produce NO cell response, + BLOCK the natural agonist
True
119
True or false:
Insulin can ONLY be taken via the s/c route
False, insulin Humulin R is used IV in DKA cases
120
What does MMSE stand for
Mini mental state examination
121
True or false:
Hearing changes with age is called Presbycusis
True
122
True or false
Normal ranges of blood sugar are from 4-6 mmol/ml
True
123
when injecting insulin what site absorbs fastest
a. behind arm
b. thighs
c. abdomen
C
124
what side of the finger should avoided bc of damaging never endings and what side should be used instead
avoid pad of finger as it has more nerve endings there
use side of the finger
125
what is insulin measured with
a. mL
b. units
c. grams
B
126
S&S of hyperglycemia
the 3 P's
- polyuria
- polydipsia
- polyphagia
127
body shaking or sweating from fear is..
a. functional hypoglycemia
b. exogenous hypoglycemia
c. endogenous hypoglycemia
A
128
an outside factor lowering blood sugar levels like putting too much insulin on and not eating
a. functional hypoglycemia
b. exogenous hypoglycemia
c. endogenous hypoglycemia
B
129
an internal factor lowering blood sugar levels like a pancreatic cancer producing too much insulin
a. functional hypoglycemia
b. exogenous hypoglycemia
c. endogenous hypoglycemia
C
130
S&S of hypoglycemia
sweating, shaking, weak, confused, hungry
131
what are the complications that can happen with constant high blood sugar
- neuropathy (loss of sensations)
- retinopathy (damage to the retina causing blurry vision and dark spots in the eyes)
- nephropathy (kidney damage)
132
