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NUR 352 > NUR 352 Exam 2 > Flashcards

NUR 352 Exam 2 Flashcards

1
Q

Name the cranial nerves

A

Oh Once One Takes The Anatomy Final Very Good Vacations Start Happening

I: Olfactory
II: Optic
III: Oculomotor
IV: Trochlear
V: Trigeminal
VI: Abducens
VII: Facial
VIII: Vestibulocochlear
IX: Glossopharyngeal
X: Vagus
XI: Accessory
XII: hypoglossal

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2
Q

Cranial nerves: Sensory, Motor, or Both?

A

Some Say Marry Money But My Brother Says Big Brains Matter More

I: Sensory
II: Sensory
III: Motor
IV: Motor
V: Both
VI: Motor
VII: Both
VIII: Sensory
IX: Both
X: Both
XI: Motor
XII: Motor

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3
Q

How do you test the olfactory nerve?

A

-sense of smell
-taste with non irritating identifying scent

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4
Q

How do you test the optic nerve?

A

-sense of vision
-test with eye chart or signs for far vision, have patient read papers for close vision
-PERRLA

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5
Q

How do you test the oculomotor nerve?

A

-motor movement of pupils
-PERRLA
-pupils constrict when looking close and dilate when looking far

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6
Q

How do you test the trochlear nerve?

A

-motor
-follow penlight 3 whiskers, looking for smooth movement

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7
Q

How do you test the trigeminal nerve?

A

-both motor and sensory
-innervates 3 parts of face: forehead, cheek, jaw
-touch with cotton ball to test sensation
-check jaw movement in all directions for motor

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8
Q

How do you test the abducens nerve?

A

-6 cardinal positions of gaze

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9
Q

How do you test the facial nerve?

A

-both motor and sensory
-ask patient to raise eyebrows, frown, puff out cheeks
-taste for sensory

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10
Q

How do you test the vestibulocochlear nerve?

A

-acoustic nerve
-sensory
-sensory: whisper test
-Romberg test for balance, assess standing balance with eyes closed

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11
Q

How do you test the glossopharyngeal nerve?

A

-both sensory and motor
-motor: assess swallowing ability, gag reflex, uvula rise
-sensory: taste in back 1/3 of tongue

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12
Q

How do you test the vagus nerve?

A

-same as glossopharyngeal (gag reflex, uvula rise, swallowing)
-bearing down

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13
Q

How do you test the accessory nerve?

A

-motor
-shrug shoulders, full ROM in head and neck with resistance

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14
Q

ambulate

A

walk

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15
Q

dermatitis

A

inflammation/irritation of the skin

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16
Q

supine position

A

person lying on their back with their face and torso pointing up

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17
Q

lateral

A

away from midline of body

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18
Q

anterior

A

towards front of body

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19
Q

posterior

A

towards back of body

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20
Q

medial

A

toward midline of body

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21
Q

midline

A

the medial line/plane of the body

halves are mirror images of each other

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22
Q

inttavenous catheter

A

IV

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23
Q

near miss

A

potential error/event that could have caused harm but was caught and avoided

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24
Q

patient safety event

A

unexpected event or circumstance that occurred without injury to the patient

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25
Q

sentinel event

A

critical, unexpected adverse event that caused severe physical or psychological harm to a client

-death, dismemberment, permanent injury, or severe, temporary injury

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26
Q

SREs

A

serious reportable events

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27
Q

another name for SREs

A

Never Events

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28
Q

Examples of SREs

A

-surgery on wrong body part
-infant discharged to wrong person
-foreign object left in patient post-op

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29
Q

delegation

A

transfer of task performance to another health team member while retaining accountability

-RNs supervise the tasks they delegate

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30
Q

When is it okay to delegate?

A

-when pt is stable
-task is within worker’s job description
-RN is able to teach and supervise
-planned how to monitor

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31
Q

When is it not okay to delegate?

A

-when there is an unpredictable outcome or increased risk of harm
-thinking, complex assessment, and judgement are required

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32
Q

Delegation steps

A
  1. assess and plan
  2. communicate
  3. ensure supervision
  4. evaluate and give feedback
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33
Q

5 rights of delegation

A
  1. right task
  2. right situation
  3. right worker
  4. right direction and communication
  5. right teaching supervision and evaluation
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34
Q

restraints

A

limit a patient’s movement; intended for safety

should always be used as a last resort

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35
Q

physical restraints

A

only appropriate for short-term use, uses physical strength to restrain

ex. swaddle wrap for insertion of iv in peds patient

36
Q

mechanical restraints

A

physical device applied such as straps, mittens, vests

37
Q

chemical restraints

A

administration of medications to reduce client movement or behavior

38
Q

barrier restraints

A

limit movement within a setting

ex. cribs for peds, bed enclosures, lapboards

39
Q

seclusion

A

environmental restraint involving placement of client alone in room

typically for patients that are very combative and pose a risk to others

40
Q

kyphosis

A

exaggerated curvatures of the thoracic spine (upper spine)

41
Q

lordosis

A

exaggerated curvature of the lumbar spine (lower spine)

42
Q

scoliosis

A

exaggerated lateral curve of the spine

43
Q

crepitus

A

rice krispy like crackles under the skin where joints are located from the friction between bone and cartilage

this is normal unless it is painful

44
Q

3 elements of nursing competency described in the Quality and Safety for Nurses (QSEN)

A

knowledge, skill, attitude

45
Q

Glasgow Coma Scale points results

A

13-15 points = minor brain injury
9-12 points = moderate brain injury
3-8 points = severe brain injury

46
Q

BADL

A

basic activity of daily living

ex. breathing, eating, sleeping

47
Q

IADL

A

instrumental activity of daily living

ex. driving, laundry, socializing

48
Q

PASS

A

-pull pin
-aim at base
-squeeze
-sweep

49
Q

RACE

A

-Rescue
-Alarm
-Confine
-Extinguish

50
Q

Normal Babinski for adults

A

-negative is good
-toes should point down towards bottom of foot (flexion)

-positive is good for babies
-toes fan outwards

51
Q

Reflex scale

A

-0-5
-0= absent
-1= weak
-2= normal
-3= brisk response
-4= hyperreflexia with non-sustained clonus
-5= hyperreflexia with sustained clonus

52
Q

clonus

A

involuntary muscle contractions caused by a permanent lesion in descending motor neurons

53
Q

What is a normal reflex on the 0-5 scale?

A

2

54
Q

TUG (timed up and go) test is used for..?

A

stroke patients and older adults

55
Q

Is velvet skin an expected or unexpected finding?

A

unexpected

56
Q

excessively smooth, soft, moist skin is a sign of …?

A

hyperthyroidism

57
Q

dorsi for feet

A

toes up

58
Q

plantar for feet

A

foot down

plant foot down

59
Q

to test shoulder ROM you would…?

A

internal rotation

60
Q

Pressure wound SATA

A

-rotate every 2 hours
-elevate (have decreased circulation to area)

61
Q

vitamin D food examples

A

salmon and tuna (fatty fish)

62
Q

calcium food examples

A

dark leafy greens and dairy

63
Q

protein food examples

A

meat, tofu, legumes, nuts

64
Q

what is a skin finding that’s expected with old age?

A

uneven pigmentation

65
Q

inflamed lymph nodes are an indication of what?

A

viral infection

66
Q

what is priority with a stroke patient?

A

maintaining airway

67
Q

what test has animals and a clock?

A

MoCA- Montreal Cognitive Assessment

68
Q

What is the Romberg test?

A

test for balance, eyes closed and arms at side

watch for sway

69
Q

What is the test for fall risk?

A

morse fall scale

70
Q

What is the test for ADL’s?

A

Roper Logan Tierney test

71
Q

What to assess in the external ear

A

tenderness, symmetry

72
Q

What is the first thing you should do if there is a fire in the staff lounge?

A

rescue/move patients first

73
Q

What statement about cyanosis and pallor requires further teaching?

A

-“pallor cannot be identified in black people”

74
Q

IADL on test

A

setting alarm clock

75
Q

What should you try before restraints?

A

bed alarms

76
Q

What is your first action with a kid with depression?

A

suicide eval

77
Q

clubbing is an indication of what?

A

low o2

78
Q

8 safety goals, SATA

A

-2 are obvious
-marking surgical site?

79
Q

which food helps musculoskeletal

A

salmon

80
Q

nutrition question about pressure ulcer healing

A

put protein

81
Q

which 2 actions are ok to delegate

A

assist to bathroom and use bed alarm

82
Q

test cranial nerve V (abducens)

A

cotton ball to face for sensation

83
Q

test CN I Olfactory

A

smell

84
Q

seizure patient SATA

A

-lower to ground
-put on side to prevent aspiration
-NOT mouth guard

85
Q

what causes pressure wounds SATA

A

only one not selected is genetics

86
Q

risk factors for ulcers

A

-edema
-decreased circulation
-nutrition

NUR 352 (4 decks)

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