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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
sentinel event
critical, unexpected adverse event that caused severe physical or psychological harm to a client -death, dismemberment, permanent injury, or severe, temporary injury
26
SREs
serious reportable events
27
another name for SREs
Never Events
28
Examples of SREs
-surgery on wrong body part -infant discharged to wrong person -foreign object left in patient post-op
29
delegation
transfer of task performance to another health team member while retaining accountability -RNs supervise the tasks they delegate
30
When is it okay to delegate?
-when pt is stable -task is within worker's job description -RN is able to teach and supervise -planned how to monitor
31
When is it not okay to delegate?
-when there is an unpredictable outcome or increased risk of harm -thinking, complex assessment, and judgement are required
32
Delegation steps
1. assess and plan 2. communicate 3. ensure supervision 4. evaluate and give feedback
33
5 rights of delegation
1. right task 2. right situation 3. right worker 4. right direction and communication 5. right teaching supervision and evaluation
34
restraints
limit a patient's movement; intended for safety should always be used as a last resort
35
physical restraints
only appropriate for short-term use, uses physical strength to restrain ex. swaddle wrap for insertion of iv in peds patient
36
mechanical restraints
physical device applied such as straps, mittens, vests
37
chemical restraints
administration of medications to reduce client movement or behavior
38
barrier restraints
limit movement within a setting ex. cribs for peds, bed enclosures, lapboards
39
seclusion
environmental restraint involving placement of client alone in room typically for patients that are very combative and pose a risk to others
40
kyphosis
exaggerated curvatures of the thoracic spine (upper spine)
41
lordosis
exaggerated curvature of the lumbar spine (lower spine)
42
scoliosis
exaggerated lateral curve of the spine
43
crepitus
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
3 elements of nursing competency described in the Quality and Safety for Nurses (QSEN)
knowledge, skill, attitude
45
Glasgow Coma Scale points results
13-15 points = minor brain injury 9-12 points = moderate brain injury 3-8 points = severe brain injury
46
BADL
basic activity of daily living ex. breathing, eating, sleeping
47
IADL
instrumental activity of daily living ex. driving, laundry, socializing
48
PASS
-pull pin -aim at base -squeeze -sweep
49
RACE
-Rescue -Alarm -Confine -Extinguish
50
Normal Babinski for adults
-negative is good -toes should point down towards bottom of foot (flexion) -positive is good for babies -toes fan outwards
51
Reflex scale
-0-5 -0= absent -1= weak -2= normal -3= brisk response -4= hyperreflexia with non-sustained clonus -5= hyperreflexia with sustained clonus
52
clonus
involuntary muscle contractions caused by a permanent lesion in descending motor neurons
53
What is a normal reflex on the 0-5 scale?
2
54
TUG (timed up and go) test is used for..?
stroke patients and older adults
55
Is velvet skin an expected or unexpected finding?
unexpected
56
excessively smooth, soft, moist skin is a sign of ...?
hyperthyroidism
57
dorsi for feet
toes up
58
plantar for feet
foot down plant foot down
59
to test shoulder ROM you would...?
internal rotation
60
Pressure wound SATA
-rotate every 2 hours -elevate (have decreased circulation to area)
61
vitamin D food examples
salmon and tuna (fatty fish)
62
calcium food examples
dark leafy greens and dairy
63
protein food examples
meat, tofu, legumes, nuts
64
what is a skin finding that's expected with old age?
uneven pigmentation
65
inflamed lymph nodes are an indication of what?
viral infection
66
what is priority with a stroke patient?
maintaining airway
67
what test has animals and a clock?
MoCA- Montreal Cognitive Assessment
68
What is the Romberg test?
test for balance, eyes closed and arms at side watch for sway
69
What is the test for fall risk?
morse fall scale
70
What is the test for ADL's?
Roper Logan Tierney test
71
What to assess in the external ear
tenderness, symmetry
72
What is the first thing you should do if there is a fire in the staff lounge?
rescue/move patients first
73
What statement about cyanosis and pallor requires further teaching?
-"pallor cannot be identified in black people"
74
IADL on test
setting alarm clock
75
What should you try before restraints?
bed alarms
76
What is your first action with a kid with depression?
suicide eval
77
clubbing is an indication of what?
low o2
78
8 safety goals, SATA
-2 are obvious -marking surgical site?
79
which food helps musculoskeletal
salmon
80
nutrition question about pressure ulcer healing
put protein
81
which 2 actions are ok to delegate
assist to bathroom and use bed alarm
82
test cranial nerve V (abducens)
cotton ball to face for sensation
83
test CN I Olfactory
smell
84
seizure patient SATA
-lower to ground -put on side to prevent aspiration -NOT mouth guard
85
what causes pressure wounds SATA
only one not selected is genetics
86
risk factors for ulcers
-edema -decreased circulation -nutrition

NUR 352 (4 decks)

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