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assessment final > Test 1 and Test 2 Review > Flashcards

Test 1 and Test 2 Review Flashcards

1
Q

Referred Pain

A

pain can originate in part of the body but be perceived in a distant organ

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2
Q

Gate Theory of pain

A

recognizers the relationship between pain and emotions

ex. stub toe- won’t grab toe you will grab foot

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3
Q

Phantom pain

A

may occur in someone who has lost a limb - may feel burning, crushing, cramping or twisted

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4
Q

Psychogenic pain

A

physical pain that cannot be identified

Ex. Sex abuse

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5
Q

Intractable pain

A

persistant pain that is resistant to therapy

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6
Q

Nociceptive pain

A

only respond to tissue damage or other intense chemical, mechanical, or thermal stimulation:

3 types
Somatic - deep pain ligaments, bones, tendons
Cutaneous - skin/subcutaneous
Visceral - organ pain

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7
Q

What does NIPS assess?

A

Neonatal
Infant
Pain
Scale

Newborn babies - rates babies on a scale of 0-1 with regard to breathing pattern, arms and leg movement, state of arousal, and crying (0-2) Higher the score can indicate problems

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8
Q

Mechanisms of pain

A

Transduction
Transmission
Perception
Modulation of Pain

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9
Q

What are things to remember when lifting?

A

Avoid twisting the thoracic spite and avoid flexion of the back; want to use the longest and strongest muscles (legs and arms) Tighten your abdominals and keep the object your going to life close to you/in your center of gravity

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10
Q

What are the 4 Ps to prevent fall

A

Every 2 hours assess:

Pain, Potty, Positiong, (IV) Pump Safety

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11
Q

Where is S2 best heard

A

at the base of the heart
**remember the base is at the top of the heart
SL closure
beginning of diastole

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12
Q

Where is S1 best heard?

A

at the Apex of the heart
** apex is at the 5th ICS below the base
AV closure
beginning of systole

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13
Q

Dextrocardia

A

when the heart is on the right side of the body and not the left

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14
Q

Bruits

A

abnormal sounds that can indicate a murmur or build up of plaque in the carotid artery (should normally sound like the ocean)

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15
Q

During percussion flatness is heard over

A

muscle/bone

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16
Q

During percussion tympanic is heard over

A

abdominals

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17
Q

During percussion resonance is heard over

A

lungs

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18
Q

During percussion dullness is heard over

A

a full bladder, lungs that might have fluid or mass in them

normal in spleen and liver

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19
Q

All People Eat Turkey Meat

A 
Apical
Pulmonic (2nd ICS)
Erbs Point (3rd ICS)
Tricuspid 4th/5th ICS (4th in kids)
Mitral/Apex (5th ICS)
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20
Q

How long would you want to listen to an apical pulse for

A

60 seconds

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21
Q

xanthelasma

A

fat deposits above eye lids (cardiac assessment)

**means they have an elevated lipid level

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22
Q

arcus senilis

A

whitish round color around the eye (typically normal in older adults)

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23
Q

What are the normal respiratory rates

A

12-20 breaths

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24
Q

What are the 6 vital signs

A

Temp, Pulse, BP, Respiration, O2 Sat

Paaaaiiiiinnnnn

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25
Q

What are the sources of heat loss

A

Skin
Evaporation of Sweat
Warming and Humidfying inspired air
Eliminating Urine and Feces

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26
Q

When is your core temp the highest/lowest

A

highest between 4-7pm and lowest in the morning

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27
Q

What and where is your best core temperature

A

Esophageal

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28
Q

Contraindications of using a rectal thermometer

A 
hemmorhoids
diarrhea
newborns
rectal bleeding/surgery
steriods
cardiac
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29
Q

Normal pulse rates

A

newborns/babies 120-160bpm

adults 60-100bpm

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30
Q

What are 2 places to assess rate in peripheral pulses

A

radial and apical

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31
Q

pulse deficit

A

difference between apical and radial pulses

32
Q

Kussamal breathing

A

shallow, rapid breathing often associated with metabolic acidosis

33
Q

Contraindications for taking BP?

A 
tremors
breast removal
vasectomy
av shunt
IV in that arm
stroke
34
Q

ausculatory gap

A

temporary disappearance of korotkoff sounds - typically between 1st and 2nd sounds

** Document and and let the provider know

35
Q

Dx of Hypertension

A

3 readings greater than 140/90

36
Q

orthostatic hypertension

A

postural hypertension - increase in BP when a person stands up — this increases peoples risk for falls

37
Q

PQRST

A 
PRECIPITATION FACTORS
QUALITY/QUANTITY
REGION/RADIATION/RELATED SYMPTOMS
SEVERITY
TIMING
38
Q

What is the review of systems

A

2 types -focused or complete health history
Includes systematic head to toe assessment
Use open ended questions

39
Q

Psychosocial assessment would include

A 
preferences for food (vegan/kosher)
activity and exercise
recreation - pets, hobbies, stress relief practices
personal habits
fears/concerns
religion
sexuality patterns
occupational/socioeconomic status
40
Q

What are the steps in the Nursing process

A 
Assessment
(Nursing) Dx
Planning
Implementation
Evaluation
Revision of care

***ADPIE

41
Q

Pitfalls to data recording

A 
omitting date
interpretation of data
assuming/hastely interpreting data (think someone automatically smokes since they smell like it)
Failure to follow up
Poor communication
42
Q

Respiratory Landmarks anterior and posterior

A

ICS 2,4,6,6

T 1,4,7,10, (9 and 5 laterally)

43
Q

Lungs bifurcate at

A

ICS 2

T 4

44
Q

Bronchial sounds

A

heard above bifurcation and expiratory> inspiratory

45
Q

Bronchialvesicular

A

heard at the bifurcation E=I

46
Q

Vesicular

A

heard below the bifurcation I>E

47
Q

hyper-resonant

A

very loud/very low - may indicate abnormal air trapping in the lungs (overinflated

48
Q

croup

A

seal like arching cough which is indicative of a narrowing of the passageway through the larynx - often in children; tx - breathing in cold air to decrease swelling (children 3months - 6 years)

49
Q

Rhonchi

A

rattling sound caused by excessive mucus

heard in the upper part of the lungs because they occur in the bronchi!

50
Q

Crackles

A

fine and course - means filled with fluid and typically heard in the lower portion of the lungs

51
Q

Shunting

A

imbalance in V/Q ratio = diversion (Ventilation fails

**if one part of the lung isn’t working properly it is going to tax the other part of the lungs for gas exchange

52
Q

pneumothorax

A

collapsed lung

53
Q

stridor

A

high pitched breath sound - typically associated with people who have croup

54
Q

Clubbing of nails could be indicative of

A

COPD or chronic smokers

55
Q

Meconium

A

first stool

56
Q

what is the proper order of assessment for the abdomen

A

Inspection
Auscultatioin
Percussion
Palpation

57
Q

What are the 4 types of abdominal distensions

A

flat
scaphoid (caved in) (thin patients)
rounded (infants and toddlers)
protuberant - pregnant women/otherwise an indication that something may be wrong

58
Q

Where is kidney and renal tenderness assessed

A

costovertebral angle

59
Q

oliguria

A

low output of urine

60
Q

anuria

A

no output of urine

61
Q

torticollis

A

lateral deviation of the neck

62
Q

cheiliosis

A

painful inflammation and cracking of the corners of the mouth

63
Q

Cognitive development during the 1st year of life is also called the ___________phase and includes what 3 major tasks

A

sensorimotor

separation (realize that self is separate from other objects)
object permanence
mental representation (recognizing symbols)

64
Q

Apgar Scale

A 
HR
Respirations
Muscle tone
Reflex Irritability
Color

**rated on a scale of 0-2 - assessed 1 and 5 minutes after birth
score of 8-10 is excellent 4-7 is guarded + 0-2 is critical

65
Q

What is the normal head circumference

A

33-35cm
microcephaly - congenital malformation/infectioin
macrocephaly - hydrocephalis (90% of normal body)

measurement of the crow to the rump should be about equal to the head circumference

66
Q

When do tears begin in a newborn

A

after 2 months

67
Q

Epstein’s pearls

A

small white pearl-like epithelia cysts on the palate are normal for newborns and disappear within a few weeks

68
Q

At what age would expect the anterior fontanels to close

A

between 12-18 months

69
Q

At what age would you expect the posterior fontanelles to close

A

3 months

70
Q

Magnet reflex

A

flexing the newborns legs and applying pressure to the soles of the feet - normal response should be extension of legs

71
Q

What type of breath sounds is normally heard in newborns

A

Bronchial

72
Q

Which vision change is frequently seen in adolescents?

A

myopia (nearsightedness)

73
Q

HEENT assessment of an adolescent what maybe be palpable owing to hormonal changes associated with puberty?

A

Thyroid

74
Q

According to Erikson what is the developmental task for the school-age children 6-12? and 12-18?

A

Industry vs Inferiority

Identity vs. Role Diffusion

75
Q

Percocious menarche

A

less than 8 years old

**normal age between 10 and 12; ovulating more = increased risk

76
Q

BRCA test

A

+ BRCA1 = 80% chance of BC

+ BRCA2 = 45% chance of BC

assessment final (7 decks)

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