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NursingTest 4 Flashcards

1
Q

What are the 6 vital signs that are taken to give some indication of a person’s state of health

A 
temperature
pulse
respiration
blood pressure
pain level
oxygen saturation
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2
Q

define metabolism

A

cellular chemical reactions in the body

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3
Q

what causes a fever and what are agents that cause fever

A

when metabolism increases, more heat is produced

pyrogens are agents that cause fever

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4
Q

what is acts as a thermostat and controls body temperature by a feedback mechanism

A

hypothalamus, located btw the cerebral hemispheres

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5
Q

when the body heat rises above normal, the hypothalamus sends out a signal through the nervous system that cause ___ ___ and ___

A

vasodilation
sweating
inhibition of heat production

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6
Q

heat loss occurs through what four ways

A

radiation
conduction
convection
evaporation

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7
Q

define pyrexia

A

fever
occurs when normal mechanisms of the body cannot keep up with the excessive heat production and body temperature rises
Temp rises above 100.2 or 37.9 C

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8
Q

define stroke volume

A

the volume of blood pushed into the aorta per heartbeat

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9
Q

define systolic pressure

A

the maximum pressure exerted o the artery during left ventricular contraction

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10
Q

define diastolic pressure

A

the lower pressure exerted on the artery when the heart is at rest btw contractions

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11
Q

What is the range of normal body temperature and what is the average temp of a young healthy adult

A
  1. 5-99.5 AND 36.4-37.5

98. 6 OR 37

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12
Q

what temperature usually indicates a fever

A

100.2 OR 37.9

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13
Q

during pregnancy, how different in the average temp and why

A

may stay at a high normal because of an increase in the patients metabolic rate

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14
Q

what are the stages of fever

A

onset=maybe be gradual/suddenly
febrile=body temp rises
defervescence=lowering of body temp

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15
Q

fevers are classified into what four categories

A

constant=continuously elevated
intermittent=temp alternates rising and falling
remittent=temp falls in morning, then rises later on in day
relapsing=temp falls to normal and then rises again in a repeated pattern

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16
Q

what are some common pulse points

A 
radial
temporal
carotid
femoral
apical, over the apex
popliteal
pedal posterior tibial
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17
Q

the apical, rather than the radial pulse, is taken on children younger than ____

A

2 years

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18
Q 
what are the average pulse rates for:
normal pulse range
some althletes
adult male
adult female
child age 5
child age 1
newborn
A 
normal pulse range=60-100
some althletes=45-60
adult male=72
adult female76-80
child age 5=95
child age 1=110
newborn=120-160
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19
Q

what are some factors that affect pulse rate

A 
age
body build and size
blood pressure
drugs
emotions
blood loss
exercise
increased body temp
pain
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20
Q

while taking the pulse, what else should be noted

A

rate
rhythm
volume

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21
Q 
What are the normal range of respirations for the age groups:
elderly
healthy adult
adolescent
child age 3
child age 1
newborn
A 
elderly=16-20
healthy adult=12-20
adolescent=16-20
child age 3=20-30
child age 1=20-40
newborn=30-80
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22
Q

what are some symptoms of hypoxia that may be noted as a result of low oxygen supply in the blood

A

apprehension and restlessness
confusion, dizziness
change in the level of consciousness
cyanosis particularly around the mouth and in nail beds

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23
Q

define eupnea

A

normal, relaxed breathing pattern

effortless, evenly spaced, regular, automatic

24
Q

define dyspnea

A

difficult and labored breathing

25
Q

define tachypnea

A

increased or rapid breathing

26
Q

define bradypnea

A

slow and shallow breathing

27
Q

define hyperventilation

A

a pattern of breathing in which there is an increase in the rate and the depth of breaths and carbon dioxide is expelled
causing blood level of carbon dioxide to fall

28
Q

define kussmaul respirations

A

increased rate and depth with panting and long, grunting exhalation
seen in pt with diabetic acidosis and renal failure

29
Q

define biot respirations

A

shallow for two or three breaths with a period of variable apnea (absence of breathing)
occur in pt with increased intracranial pressure

30
Q

define Cheyne-Stokes respirations

A
  • pattern of dyspnea followed by a short period of apnea
  • respirations are faster and deeper, then slower and are followed by a period of no breathing
  • pt who is critically ill, brain conditions, heart or kidney failure, drug overdose
31
Q

define crackles

A

abnormal, nonmusical sound heard on auscultation

also called rales

32
Q

define rhonchi

A

continuous dry, rattling sounds caused by partial obstruction

33
Q

define stertor

A

snoring sound produced when pt is unable to cough up secretion from the trachea or bronchi

34
Q

define stridor

A

crowing sound on inspiration caused by obstruction of the upper air passages as occurs in croup or laryngitis

35
Q

define wheeze

A

whistling sound of air forced pas a partial obstruction

found in asthma or emphysema

36
Q

what is pulse pressure

A

the difference between systolic and diastolic pressure

EX: 120/80=120-80=40

37
Q

why should a pt not cross their legs when a blood pressure is being taken

A

it cause an elevation in systolic and diastolic pressure

38
Q

prolonged hypertension can cause permament damage to the __, __, __, and __ of the eye.

A

brain
kidneys
heart
retina

39
Q

what are some causes of shock

A 
hemorrhage
vomitting
diarrhea
burns
myocardial infarction
40
Q

what are some signs of shock

A 
decrease in BP
increase in HR
cold and clammy skin
dizziness
blurred vision
apprehension
41
Q

pain assessment must include

A 
location
intensity
character
frequency
duration
42
Q

temperature measurement through ___ is the closest to core body temperature

A

tympanic

43
Q

a CNA reporst to the nurse that the T of a pt who is 1st day postoperative is 100.2F. Which action should the nurse take?

A

tell CNA to take T again in 2 hours

44
Q

T greater than 105.8 should be treated promptly to reduce the fever because of what?

A

potential damage to the cells of the CNS

45
Q

a newly admitted pt has a respiratory rate of 16/minute. which action should the nurse take

A

note the rate on the chart, respiratory rate is normal

46
Q

a pt who makes harsh high sounds on inspiration has what kind of respiratory condition

A

stridor

47
Q

what are the physical examination techniques

A 
inspection and observation
palpate
percussion
auscultation
olfaction
48
Q

define lordosis

A

exaggerated lumbar curve

49
Q

define kyphosis

A

increased curve in the thoracic area

50
Q

define scoliosis

A

pronounced lateral curvature of the spine

51
Q

when documenting pupils, what does PERRLA mean

A 
pupils
equal
round
reactive
light
accommodation
52
Q

define nystagmus

A

jerky movements

53
Q

in Glasgow coma scale, what is highest possible score, and what indicates a coma

A

15

7

54
Q

when assessing a complaint of bloating and gas, you would assess for air within the intestines by ___

A

percussion

55
Q

wet, crinkly sounds heard on auscultation of the lungs are referred to as _____ and indicate ___

A

crackles

moisture in the lungs

old tests (16 decks)

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