test 1 nursing theory Flashcards
What are some general data that you can obtain just from observing and interacting with your client
physical appearance with regard to clothing and hygiene, level of consciousness, body size, posture, gait and coordinated movement, use of ambulatory aids, mood and emotional tone
what is included in a mental status assessment
attention, concentration, memory, and ability to think abstractly
what is examined during an eye assessment
appearance of the eyes, iris, sclera, corneas, eyelashes
what is the purpose of the weber test
technique used for determining equality or disparity of bone-conducted sound
what is the purpose of the rinne test
technique used for comparing air versus bone conduction of sound
normal oral and mucous membrane should appear
pink, intact, and kept moist by salivary glands located below the tongue
define wound
a break in the skin
define ulcer
an open, crater-like are
define abrasion
an area that has been rubbed away by friction
define laceration
a torn, jagged wound
define fissure
a crack in the skin, especially in or near mucous membranes
define scar
a mark by the healing of. a wound or laceration
identify the term pailor (pale)
pale regardless of race
identify the term erythema
red, superficial burns, local inflammation, carbon monoxide poisoning
identify the term ecchymosis
purple-trauma to soft tissue
identify the term flushed
pink-fever, hypertension
identify the term cyanosis
blue- low tissue oxygen
identify macule
flat, round, colored, non palable area- freckles
identify papule
elevated, palpable, solid- wart
identify vesicle
elevated, round, filled with serum - blister
identify wheel
elevated, irregular border, no free fluid- hives
identify pustule
elevated, raised border, filled with pus- boil
identify lordosis
exaggerated natural curve of the spine
define kyphosis
an increased thoracic curve
define scoliosis
pronounced lateral curvature of spine
s1 heart sound
lub sound is louder at the apex
s2 heart sound
dub sound heard in the mitral area
define tracheal sounds
loud and course
define bronchial sounds
harsh and loud
efine bronchovesicular sounds
medium range sounds equal in length with inspiration and expiration
define vesicular sounds
soft rustling quality is longer in inspiration
define crackles (rales)
intermittent, high pitched, popping
define gurgles (ronchi)
low pitched, continuous bubbling, and heard in larger airways
define wheezes
whistling or squeeking sounds caused by air moving through a narrowed passageway
defin rubs (pleural friction)
grating, leathery sounds caused by two dry pleural surfaces
what is edema
excessive fluid within tissue, abnormal fluid distribution
what is the order of abdomen inspection
inspected, auscultated, palpation and percussion
what is an anal fissure
a small tear in the thin, moist tissue that lines the anus
when should cervical collars be worn
10 days to 2 weeks
whats the purpose of a sling
to elevate, cradle and support parts of the body
what is the purpose of traction
reduce muscle spasms, realign bones, relieve pain, prevent deformities
what should a nurse observe for when a client is walking
pallor, dizziness, weakness
define negligence
harms that results because a person did not act accordingly
define fidelity
being faithful to work related commitments and obligations
define veracity
duty to be honest and avoid decieving or misleading a client
define benficence
doing good or acting for anothers benefit
what is the order of assessing bowel sounds in the head to toe
rlq, rlq, ruq, luq, llq
what is bucks and russels traction
when tape or some type of material is stuck to the skin and the wight pulls against it.
