Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Sprinig 2018 > N388 Unit 2 > Flashcards

N388 Unit 2 Flashcards

1
Q

Factors that influence personal hygiene

A

*Maintaining cleanliness and grooming of the external body

  • Implications for NOT maintaining standard of care:
  • Increased risk of infection or illness
  • Social and psychological aspects can be affected
  • Potential for violating cultural and religious considerations

**Do not force changes in hygiene practices unless it affects patients health
EX: IV’s need to be cleaned, can lead to infection

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Types of hygiene a nurse can provide

A 
General grooming
Back care
Perineal care
Foot care
Oral hygiene
Hair care
Nail Care
Shaving
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Reasons for providing personal hygiene

A

Promotes good habits of personal hygiene
Provides comfort and stimulates circulation
Helps improve self-image
Opportunity to develop a good and caring relationship with the patient

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Types of baths

A
  • Complete bed bath: includes all parts of the body & oral
  • Partial bed bath: some parts of body; “sponge bath at the sink” provide assistance with hard to reach places
  • Tub bath or shower: provide towels and supplies/prepare tub or shower
  • Bag bath: pre-moistened clothes in a solution of no rinse surfactant cleanser and emollient dry shampoos
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Self-care ability depends on patients condition and…

A 
Ability to help
Mental status
Muscle strength
Flexibility
Visual acuity
Ability to detect thermal and tactile stimulus
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Considerations Across Lifespan

A

Gentle handling of neonates

Toddlers/School-age active play

Adolescence growth and maturation (know what is happening, what to expect)

Older adults- skin care changes

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Safety principles for nurse during personal hygiene

A 
Ensure bed is at working height
Ask for assistance if needed
Keep side rails up on side opposite
Maintain proper body mechanics
Wear gloves soiled linen or open lesions
Keep soiled linens away from uniform
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Reason for Intake/Output

A

Helps us determine the patient’s fluid status

Hydrated?/Dehydrated?/Fluid overload?

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What do you measure for intake

A

Oral fluids- water, milk, coffee, tea, soda, juices, ice chips;

Foods that tend to become liquid at room temperature (pudding, jello, ice-cream)

Tube feedings parental fluids (IV) catheter or tube irrigants

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Units of measure

A

Milliliter (mL)
1 FL = 30 mL
1 pint = 500 mL
1 quart = 1,000 mL

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Recording intake

A 
Often have to estimate
Convert all to mL’s
Coffee cup (8oz=240 mL)
Water pitcher (1000 mL)
Soup bowl (6 oz = 180mL)
Jello (4oz = 120 mL)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What to measure for Output

A 
Urinary output
Bowel movements
Vomitus or liquid feces
Tube drainage
Wound drainage or wound fistulas

Be descriptive: color, consistency of urine, stool, etc.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Circulation of blood through heart

A 
Inferior vena cava
Superior vena cava
R. atrium
Tricuspid valve
Right ventricle
Pulmonic valve
Pulmonary artery
Lungs
Pulmonary vein
Left Atrium
Mitral Valve 
Left ventricle
Aortic valve
Aorta
Body
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Chambers of the heart

A

Right atrium
Right atrium
Receives oxygen-poor blood from the body and pumps it to the right ventricle.

Right ventricle
The right ventricle pumps the oxygen-poor blood to lungs.

Left atrium
The left atrium receives oxygen-rich ; blood from the lungs and pumps it to the left ventricle.

Left ventricle
The left ventricle pumps the oxygen-rich blood to the body

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Blood vessels of heart

A

Arteries
Veins
Capillaries

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Arteries

A

Carry oxygen blood away from heart to tissues

Arteries begin with the aorta, the large artery leaving the heart.
They carry oxygen-rich blood away from the heart to all of the body’s tissues.
They branch several times, becoming smaller and smaller as they carry blood further from the heart.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Veins

A

Take oxygen poor blood back to the heart
Veins become larger and larger as they get closer to the heart.

The superior vena cava is the large vein that brings blood from the head and arms to the heart, and the inferior vena cava brings blood from the abdomen and legs into the heart.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Capillaries

A

Thin blood vessels that connect arteries and veins;

Their thin walls allow oxygen, nutrients, carbon dioxide and waste products to and from the tissue cells.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Valves of heart

A

Semilunar valves:
Aortic & pulmonary valves
In arteries leaving heart
At the bases of the aorta and the pulmonary artery, consisting of three cusps or flaps that prevent the flow of blood back into the heart.

Atrioventricular valves:
Mitral (bicuspid) & tricuspid valves
Between the upper (atria) chambers and lower chambers (ventricles)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Pericardium

A

Double walled sac heart is located in

Fibrous Pericardium (outside): dense connective tissue, anchors it while beating 
Serous Pericardium (inside): 3 layers, visceral pericardium (innermost), serous fluid, parietal pericardium
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Layers of the heart

A

Epicardium, Myocardium, Endocardium

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

General system of heart

A

All areas (chambers/valves/veins/arteries) work toether to circulate blood around your body

Fluid likes to move from areas of high pressure to areas of low pressure

The heart creates these pressures

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

4 valves of heart

A

Pulmonary semilunar valve:
Mitral Valve- (bicuspid valve)
Aortic semilunar valve:
Tricuspid Valve:

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Aortic Seminilunar Valve

A

between the left ventricle and the aorta which carries blood from the heart to the rest of the body

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Mitral vavle

A

(Bicuspid valve) between the left atrium and the left ventricle

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Tricuspid valve

A

between the right atrium and the right ventricle

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

Pulmonary semilunar valve

A

between right ventricle and pulmonary artery allows blood to flow from heart to lungs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

Lub-dub

A

blood travels through one valve, can’t go back; this sound is the valves opening and closing

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

Atria

A

Receiving chambers of blood coming back to the heart form body (thin walled)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

Ventricles

A

Discharging out of heart (much thicker)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

Steps of Blood Circulation

A

Blood out of semilunar valve into pulmonary trunk

Deoxygenated blood in pulmonary arteries leaves heart and goes to lungs; picks up O2

Circles back to heart via pulmonary veins, finding area of lowest pressure (left atrium)

Left atrium contracts, leaves through mitral valve into left ventricle Steps 1-4 Pulmonary Circuit Loop-now have oxygenated blood

From Left ventricle goes to aortic semilunar valve, rounding through the aorta and going to the rest of the body

Oxygen poor blood then returns to heart vai superior vena cava and inferior vena cava into right atrium

When right atrium contracts, send it through tricuspid valve, into right atrium Steps 5-7 is systemic loop

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

Lub

A

S1 sound
Closure of AV valves (tricuspid & mitral)
Start of systole
Loudest at apex (expected finding)

Low systolic=low blood volume, maybe lost a lot of blood or dehydrated

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

Dub

A

S2 sound
Closure of semilunar valves (pulmonary and aortic)
End of systole/Start of diastole
Loudest at base (expected finding)

High diastolic- pressure could be high even with lower systolic number

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

Grade strength of pulses

A 
0 absent (get 2nd opinion)
1+ weak, diminished, barely palpable
2+ normal, expected finding
3+ full or increased (bounding)
4+ bounding
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

Capillary refill

A

should be less than 2 seconds

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

Standard precautions

A

Assumes blood and body fluid of any patient could be infections
Hand hygiene
Personal protective equipment as warranted
Safe injection practices
Safe handling of potentially contaminated equipment or surfaces
Respiratory hygiene/cough etiquette

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

Transmission-based precautions

A

Used in addition to standard precautions when there is an increased risk

Contact
Airborne
Droplet
SPecial enteric?
Special airborne?
Special droplet
Others?
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

CDC vs. Health Institution

A

CDC considers public safety (will likely stick to contact, airborne, and droplet)

Health institution monitors the safety that facility and the threat that exists across that population

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

PPE

A

Personal Protective Equipment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

HAI

A

Hospital Acquired Infection

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

SSI

A

Surgical Site Infection

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

CLABSI

A

Central Line Associated Bloodstream Infection

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

CAUTI

A

Catheter Associated Urinary Track Infection

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

MRSA

A

Methicillin Resistant Staphylococcus Aureus

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
45
Q

VRE

A

Vancomycin Resistant Enterococci

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
46
Q

C. Diff

A

Clostridium Difficile

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
47
Q

Types of PPE

A

Gloves
Gowns
Face protection (masks/shields/goggles)
Respiratory protection (face mask/respirator)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
48
Q

Gloves

A

Purpose: patient care, environmental
Material: vinyl, latex, nitrile
Sterile or nonsterile
Single use

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
49
Q

Gowns

A 
Used with a lot of bodily fluids
Purpose: protect skin and/or clothing from fluids, secretions
Material: resistant to fluid penetration
Reusable or disposable
Clean or sterile
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
50
Q

Face Protection

A

Masks
Protects nose and mouth
Should be fully covered

Goggles
Protects eyes
Should snuggly fit over and around
Personal glasses not a substitute for goggles

Face Shields
Protects face, nose, mouth, and yes
Should cover forehead, extend below chin and wrap around side of face

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
51
Q

Respiratory Protection

A

Purpose: protect from inhalation of infectious aerosols

PPE types for respiratory protection

  • Particulate respirators
  • Half- or full-face elastomeric respirators
  • Powered air purifying respirators (PAPR)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
52
Q

Don

A 
= put on
Gown
Mask/respirator
Goggles or face shield
Gloves
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
53
Q

Doff

A

= take off (most dirty/contaminated first)

Gloves
Gown
Face shield or goggles
Mask or respirator

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
54
Q

Contact Precautions

A

prevent transmission of agents spread by direct contact with patient or environment

Types of patients: skin infections, rashes, MRSA, VRE< excessive wound drainage, fecal incontinence

PPE:
Hand hygiene
Gloves & gowns are required
Others as appropriate

Care of patient:
Patients with infectious diarrhea need to use a separate bathroom
Dedicated patient material

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
55
Q

Special Enteric Precautions

A

is a subset of contact for things particularly worried about

Types: C diff, norovirus, rotavirus
Same PPE but Soap and Water

brown box

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
56
Q

Droplet Precautions

A

prevent transmission of agents spread through close respiratory or mucous membrane contact with respiratory secretions

Agents: pertussis, influenza, adenovirus, rhinovirus, streptococcus

PPE:
hand hygiene
Face mask
Others as appropriate

Care of patient:
Private room or with patient with same infection
Patient wears mask when exiting room

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
57
Q

Airborne Precautions

A

prevent transmission of agents that are disseminated in droplets or dust particles remains infectious over long distances when suspended in the air

Agents: tuberculosis, measles, chickenpox

PPE:
Hand hygiene
N-95 (respirator mask) donned before entry/removed after exit
Others as appropriate

Care of patient
Private room
Negative pressure isolation room is required
Patient wears face mask out of room

58
Q

Nursing responsibility: W’s behind the order

A

Why is this ordered?
What is this for? What makes us think this test is needed?
When should it be done? When will results be back?
Where do I get the specimen from?
Where does it go?
What do I need in order to obtain this specimen?
What does the patient need to know?
What happens after the results are back?

59
Q

Restraints

A

Devices used to limit physical activity or movement of a part of the body; can be physical or chemical

60
Q

Negative outcomes from restraint use

A

Physical
Emotional
Substandard care
Death

61
Q

Alternatives to restraint

A

Environment

Treat underlying cause of restlessness or agitation

62
Q

Nursing care of patients in restraints

A

Apply restraints per institutional protocol
Provider must enter prescription (order) for restraints
Follow institutional protocol for monitoring and safety checks
Offer food and fluids
Assess circulation of restrained extremity
Assist with elimination
Assess skin integrity
Assess frequently/document frequently
Assess need for continued restraints
Create soothing environment
Remind them it is temporary and why they have it

63
Q

What isn’t a restraint?

A

Devices used to immobilize patient during a diagnostic procedure

Orthopedic supportive devices

Helmets or age-appropriate protective equipment, such as strollers or cribs

Keeping all side rails up on a bed for seizure precautions

64
Q

Goal regarding restraints?

A

Restraint free environment

65
Q

Less restrictive restraints

A

Less: Mitts, full arm cuffs
More: leather cuffs, vests

66
Q

Nurse role during first visit

A 
Height &amp; weight
Baseline blood pressure
Test urine for ketones, protein &amp; glucose
Draw labs
CBC (HCT/Hgb)
Type &amp; RH
Rubella Titer
Serology (STDs)
HIV Antibody
Dependent on history
Sickle cell
Complete urinary analysis
67
Q

Nagel’s Rule

A

Gestational Age of the Pregnancy

First day of the last menstrual period
Add 7 to the date
Count back 3 months
Due date (EDD= Expected due date)
EX: Jan. 9, 2017 +7 = 16, - 3mo. = 10/16/18
68
Q

Gravida Para

A

Pregnancy history:
First time pregnant GRAVIDA 1
Never given birth to any children PARA 0
G1P0

69
Q

Physician first visit/bimanual exam

A

Bimanual exam (2 fingers in vagina, 1 on abdomen, push uterus up to hand)- gives sense of size; measure with fingers until 20 weeks then use tape measure;

The nurse is always present in the room; prepares patient, comfort her, help her relax, stay there

Need to make sure the yolk sac lined up and is not in Fallopian tubes; at 5 weeks it could shatter tube
If patient is suddenly bigger- could be twins

Due date is determined by ultrasound and pelvic exam

Nurse takes heart tones to see if pregnancy is along as you think

70
Q

Term pregnancy

A

37-42

37(before premature) - 42 weeks (after post-mature)
Next day would be 7th day so 6.0

Don’t induce unless you medically have to

Placenta is not meant to live longer than 42 weeks, baby won’t get correct nutrients after that

71
Q

Gestational Age in Weeks

A

Gestational Age in Weeks from the LMP (last menstrual period)

5 weeks, 6 days = 5.6
next day would be 6.0

72
Q

Education during initial prenatal visit

A

Nutrition 25-35 lobs for the pregnancy

Counteract nausea and vomiting
*At about 12 weeks the placenta with hormones takes over and N&V should go down)
N&V is most common discomfort, try low fats, fruit smoothies, small frequent meals, bland diet

Signs and symptoms to call provider

Exercise
-Low impact, don’t start anything new

Sex
- safe positions, continue to do it

When to return to clinic (4 weeks)

73
Q

Trimesters

A

1st: conception to 12 weeks
2nd: 13 to 26 weeks
3rd: 27-40+ weeks

74
Q

1st Trimester

A 
Nutrition
Exercise
Danger signs (especially bleeding)
Common discomforts
Avoidance of toxic substances (household chemicals, smoke, street drugs, alcohol)
Sexuality
Reaction to pregnancy: Ambivalence
Genetic testing (referral)
75
Q

2nd Trimester topics

A 
“Acceptance stage”
Infant feeding
How to get baby out of body
What has to change in family dynamic (prepare children, baby sleeps)
Signing up for birthing classes
Circumcision- both sides
76
Q

3rd trimester

A 
Birth center vs. hospital
Signs and symptoms of labor (true vs false)
What to pack for hospital
Birth control methods
Baby care
How to go back to work
77
Q

Clinic visits based on gestational age

A

After the first visit: 6 weeks to 28 weeks gestation= every 4 weeks
28-36 weeks = every 2 weeks
36-40 weeks = every week
40-birth = 2x a week

78
Q

Composition of gestational visits

A 
Weight
Blood pressure
Screen for symptoms
Listen for heart tones, estimate of fetal size
Labs by trimester
Teaching topic by gestation
79
Q

Developmental components in pediatrics

A

Physical

Cognitive(Piaget)- how kids learn/think/reason

Psychosocial(Freud)- parts of kids bodies at certain stages

Psychosocial (Erickson)- conflicts in children to make one trust vs. mistrust

80
Q

Infant approach

A

Approach in parent’s lap, listen when they are quiet, leave uncomfortable stuff for last, beware of pee

81
Q

Toddler approach

A

Approach: Most challenging, talk to parent first, allow to touch equipment, leave uncomfy for last

82
Q

Preschool approach

A 
Approach: More cooperative but still need parents close by
Erickson: give jobs, getting independent
Have them tdo jobs
Handle equipment, play
Head to toe
Get things in order that you can
83
Q

School age approach

A

Approach: warm up, ask them questions too, head to toe, respect modesty, time to teach

84
Q

Adolescent approach

A

Approach: who will be present and for what part, talk to them both individually, head to toe, invite parent back after exam, puberty, talk about normal

85
Q

Anthropometric Measures

A 
Weight, height, head circumference, BMI
Growth charts (trends)
Trends are most important
Changes in any of the above may be the first sign of a serious health status change
86
Q

Infancy (Physical Development)

A

Birth weight doubles by end of first 6 months, triples by end of year 1
Birth length increased by about 50% by end of year 1
Rapid growth in brain and body
Tone, strength and coordination increase from head to toe
Early intervention is key if anything is abnormal
Need opportunity to play with toys and food

87
Q

Toddlers/Preschool (Physical Development)

A

Birth weight quadruples by 2 ½ years, yearly gain 4.4-6.6 lbs
Height at 2 years is approx 50% of eventual adult height
Height gain during 2nd year- 4.8 in during 3rd year 2.4-3.2 in
Increase in strength, coordination and dexterity; fearless and tireless

88
Q

School age (Physical Development)

A

Yearly weight gain 4.4-6.6 lbs

Yearly height gain after 6 years of age- 2 in

89
Q

Female Adolescent (physical Development

A

Growth spurt 10-14 years
Weight gain 15-55 lbs (mean 38lbs)
Height gain 2-10 in;
95% of mature height achieved by menarche or skeletal age of 13

90
Q

Male Adolescent (Physical Development)

A 
Male
Growth spurt 12-16 years
Weight gain 15-65 lbs (mean 52 lbs)
Height gain 4-12 in (mean 11) 
95% of mature height achieved by skeletal age of 15 years
91
Q

Health History of Pediatric

A 
Perinatal, obstetric history 
Birth- wt, apgar, overall health
Immunization
Growth and development- major milestones
Habits &amp; other hot topics

*who is giving this information?

92
Q

Temperature in kids

A

Route
Key points: Document site, trends are important, validate if out of range
Rectal- only if exact measurement is needed
Tympanic- down and back if less than 3; up and back if over 3
Axillary- Infant, young children, immunosuppressed, oral surgery, neuro impaired
Oral- older than 5 ot 6

93
Q

Pulse in kids

A 
See specific guidelines
Apical site if less than 2, history of CHD or irregular
Less than 7 left MCL and 4th ICS
Older than 7 left MCL and 5th ICS
Radial for all others
Count for one minute
Changes with breathing are normal
94
Q

Respiration in kids

A

See specific guidelines
Count for 1 full minute
Periodic breathing is normal
Auscultate especially in infant, young child

95
Q

Blood Pressure in kids

A 
Save for last
Appropriate cuff size is a must
“Hug” feel how strong
Upper arms and legs
Document site, stay with same site
Normal- age, height, gender
96
Q

Fontanels

A

Posterior closes: 2-3 months

Anterior closes: 12-18 months

97
Q

10 Rights of Medication Administration

A 
Medication
Dose
Time
Route
Client/Patient
Education
Documentation
..to Refuse
Assessment
Evaluation
98
Q

Purposes of medication administration

A 
Pain
Nausea
Swelling
Illness
Health promotion
Disease prevention
99
Q

Pharmacological Concepts Overview

A

Classification of drugs (family)
Similar characteristics

Name of drugs
Brand or trade name
Generic

Form of drug
Tablet, caplet, capsule, elixir
Injection, ointment, suppository

100
Q

Role in Medication Administration

A

Prescribe: Physician, Nurse Practicioner, Dentist, Physician Assistants

Prepares & Distributes: Pharamacist (Pharmacy Tech)

Prepare, administer, evaluate response: Nurses (RN & LPN)

101
Q

Types of Orders

A

Standing orders or routine orders (carried out until cancelled or limits up)
PRN orders: As needed
Single orders: given just once
STAT orders: immediately once

102
Q

Standard Assessment vs. Focused Assessment

A 
SA: 
Exam techniques, I, P, P, A
Some subjective data 
Establishes baseline/used for comparing subsequent assessments
Completed at certain “times”
VS important
FA:
Examp techniques: I, P, P, A
Problem based: actual or at-risk
More subjective 
Establishes baseline/used for comparing subsequent assessments
Used to identify changes in clinical status
More frequent than standard assessments
VS important
103
Q

Focused Assessment

A

Problem based (actual or at-risk problems)
Individualized: problem based
More in-depth than standard
Includes subjective data
Extends to related systems
Physical assessment but extends to psycho-social
May be conducted more frequently than standard

104
Q

When to do a focused assessment

A

Nursing knowledge
Institutional policy
Unexpected findings in a standard assessment
Clues from patients/family members

105
Q

Focused Neuro (Subjective/Objective)

A 
Subjective:
Review of system
Reason for visit or problem
“Pain” “Weakness” “Dizziness:
Prior head injury/other related injury/surgery/limitations
Objective:
HEENT
Inspect and palpate head
TMJ (I &amp;P)
Eyes (Symmetry,PEERL, EOMs
Ears (I &amp; Assess hearing)
Face (Assess motor functiono f CN VII)
106
Q

C.N. I

A

Olfactory: Sensory: Smell

107
Q

C.N. II

A

Optic: Sensory: Vision

108
Q

C.N. III

A

Oculomotor: Mixed

Motor- most EOM movement, opening of eyelids
Parasympathetic- pupil constriction, lens shape

109
Q

C.N. IV

A

4- Trochlear: Motor

Down and inward movement of eye

110
Q

C.N. V

A

5- Trigeminal: Mixed

Motor- muscles of mastication
Sensory- sensation of face and scalp, cornea, mucous membranes of mouth and nose

111
Q

C.N. VI

A

6- Abducers Motor

Lateral movement of eye

112
Q

C.N. VII

A

7- Facial Mixed

Motor- facial muscles, close eye, labial speech, close mouth
Sensory- taste (sweet, salty, sour, bitter) on anterior two thirds of tongue
Parasympathetic- saliva and tear secretion

113
Q

C.N. VIII

A

8 Acoustic Sensory

Hearing and equilibrium

114
Q

C.N. IX

A

9 Glassopharyngeal- Mixed

Motor- pharynx (phonation and swallowing)
Sensory: taste on posterior one third of tongue, pharynx (gag reflex)
Parasympathetic- parotid gland, carotid reflex

115
Q

C.N. X

A

10- Vagus- Mixed

Motor- pharynx and larynx (talking and swallowing)
Sensory- general sensation from carotid body, carotid sinus, pharynx, viscera)
Parasympathetic- carotid reflex

116
Q

C.N. XI

A

11- spinal- motor

movement of trapezius and sternomastoid muscles

117
Q

C.N. XII

A

12- hypoglossal- motor

movement of tongue

118
Q

Pupillary light reflex

A

Assesses CN II and III

Direct and consensual response to light (both sides)

119
Q

Extraocular Movements

A

Six Cardinal Positions of Gaze

Assesses function of CN III, IV, VI (3, 4, 6)

120
Q

Snellen chart

A

alphabet letters 20 ft away (20/20)

20/40 would be can see at 20 feet what others can see at 40

121
Q

Rosenbaum card

A

same idea as snellen but at 14 inches

122
Q

Focused musculo-skeletal (subjective/objective)

A

Subjective
Review of system
MS System: pain, limited function, injury
History of injury/illness/surgery/limitations

Objective:
Inspect (symmetry, deformities) and palpate for tenderness, warmth, muscle tone/strength
Active ROM
Muscle strength
0- no strength
1- 10% normal strength
2- 25% normal strength
3- 50% normal strength
4- 75% normal strength
5- 100% normal strength
ROM cervical/lumbar spine: flexion/extension
Upper extremities (shoulders/elbows/wrist/fingers)
Lower extremities (hips/knees/ankles/toes)

123
Q

Medication education

A

side effects, safety concerns, why getting what giving

124
Q

Essential components of medicine order

A

Patient name
Generic name
Dosage/route/frequency/time

125
Q

EMAR

A

Electronic Medication Administration Record

126
Q

NKDA

A

No known drug allergies

127
Q

PRN

A

as needed

128
Q

BID

A

2x/day

Not necessarily every 12 hours, may be diuretic

129
Q

Q12

A

Every 12 hours

130
Q

TID

A

3x/day (usually related to meals)

131
Q

HS

A

@ bed time

132
Q

Tanner Scale

A

used to measure physical development on external primary and secondary sex characteristics such as size of breasts, genitals, testicular volume and development of pubic hair

133
Q

Rooting reflex

A

begins when corner of baby’s mouth is stroked the baby will turn towards and open his or her mouth; used to find breast

134
Q

Suck reflex

A

stroke inside of mouth, baby will begin sucking

135
Q

Moro reflex

A

startled baby; baby throws back his or her head and extends arms and legs then pulls it all back in

136
Q

Tonic neck reflex

A

“fencing position” head turned to one side, arm pointed in that direction

137
Q

Grasp reflex

A

stroke palm they will close their hands around finger

138
Q

Babinski

A

sole of foot stroked they will spread toes

139
Q

Step reflex

A

when held upright they appear to be taking steps

140
Q

Girls: Secondary Sex Characteristics

A

7- Breasts
8- Pubic hair
8- Vagina grows larger and outer lips (labia) more pronounced
9- body taller and heavier
11- Hair begins to grow under arms
11 Glands in skin/scalp produce more = blemishes

141
Q

Boys: Secondary Sex Characteristics

A 
10- testicles enlarge and scrotum darker/coarser
10- Pubic hair 
10- Body grows taller and heavier
11- Penis longer/fuller
11- Voice deepens
11- Become fertile
12- Hair under arms and on face
12- Glands in skin/scalp produce more= blemishes

Sprinig 2018 (6 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions