Test 1 Study Guide Flashcards
1
Q
Attitudes, knowledge, and skills necessary for providing quality care to diverse populations
A
Cultural competence
2
Q
Verbal responses that promote interview
A
Positive interview
3
Q
Verbal responses that promote interview
Patient’s or examiners perspective?
-Silence
-Reflection
- empathy
- clarification
A
Patient’s
4
Q
Verbal responses that promote interview
Patient’s or examiners perspective?
- confrontation (clarification)
- interpretation
- explanation
- summary
A
Examiners
5
Q
4 types of data
A
-Complete
- focused or problem- centered
- follow up
-Emergency
6
Q
Types of data
Complete health history and full physical exam
A
Complete
7
Q
Types of data
One problem, cue complex, or body system
A
Focused or problem centered
8
Q
Types of data
Evaluating the identified problems at regular or appropriate intervals
A
Follow-up
9
Q
Types of data
Urgent rapid collection of information
A
Emergency
10
Q
Percussion sounds
Low pitched, hollow sounds, medium-loud amp, moderate duration
A
Resonant
11
Q
Percussion sounds
Low pitched, hollow sound, medium-loud amp, longer duration
A
Hyporresonant
12
Q
Percussion sounds
High pitch, drumlike, loud amp, longest duration
A
tympany
13
Q
Percussion sounds
High pitch, muffled thud, soft amp, short duration
A
Dull
14
Q
Percussion sounds
High pitch, absolute dullness, very soft amp, very short duration
A
Flat (extremely dull )
15
Q
Stethoscope side best for high pitched sounds
A
Diaphragm
16
Q
Stethoscope side best for hearing breath, bowel, and normal heart sounds
A
Diaphragm
17
Q
Stethoscope side best for hearing soft pitched sounds
A
Bell
18
Q
Stethoscope side best for hearing extra heart sounds or murmurs
A
Bell
19
Q
Most accurate temperature route
A
Rectal
20
Q
Normal heart rate
A
60-99
21
Q
Heart rate under 59 beats/min
A
Bradycardia
22
Q
Heart rate above 100 beats/min
A
Tachycardia
23
Q
3 reasons for heartrate to go up
A
-Stress
- Exercise
- sodium
24
Q
When does blood pressure rise?
A
Late Afternoon
25
When does blood pressure decline
Early morning
26
How long should you count vitals if abnormal
Full 60 seconds
27
Emotional and cognitive function
Mental status
28
State of well being in which every individual realizes his or her own potential, can cope with normal stress of life, can work productively and able to make contributions to the community
Mental health
29
A patients response is much greater than the expected reaction to a traumatic event
Mental disorder
30
4 ways to assess mental status
- Appearance
- behavior
- cognitive function
- thought process
31
5 levels of consciousness
- Alert
- lethargic
- obtunded
- stupor/semi coma
- coma
32
3 types of aphasia
- broaca's aphasia
- wernicke aphasia
- global
33
Type of expressive aphasia where
The person knows what he or she wants to say, but cannot produce the correct word Ir statement
Broacas aphasia
34
Type of receptive aphasia where
Severe comprehensive difficulty (word salad)
Wernike
35
Type of wide spread aphasia where
Reduced or absent comprehension
Global aphasia
36
Acute confusional state that is preventable
Delirium
37
Chronic progressive loss of cognitive and intellectual functions
Dementia
38
Long-term depressed mood of at least 2 weeks
Depression
39
Ranges for BMI ( 5 )
- Underweight
- normal weight
- Overweight
-obesity
- extreme obesity
40
Range for underweight BMI
Anything Under 18. 5
41
Range for normal BMI
18.5 - 24.9
42
Range for overweight BMI
25 - 29.9
43
Range for obese BMI
30-39.9
44
Range fur extreme obesity BMI
40 and up
45
Lack of proper nutrition
Malnutrition
46
Occurs when nutritional reserves are depleted and/or when nutrient intake 1s inadequate to meet day-to- day needs or added metabolic demands
Undernutrition
47
5 risks for undernutrition
- Impaired growth and development
- lowered resistance to a disease and infection
- delayed wound healing
- longer hospital stays
- higher healthcare costs
48
What are these biomarkers for?:
- waist circumference
- blood pressure
-Triglycerides
- glucose
- high density lipoproteins
Metabolic syndrome
49
What vitamin deficiency:
Causes dry, flakey skin, foamy plaques on eyes, eye dryness
Vitamin A
50
What vitamin deficiency causes:
- petechia/ ecchymosis, bleeding, jointpain
Vitamin C
51
What vitamin deficiency causes:
Dry, flaking skin ) glottis (red, swollen tongue ) blepharitis of eyes
Vitamin B complex
52
Nails angled down > 180 degrees
Clubbed nails
53
What conditions is clubbed nails prevalent
- congestive heart disease
- lung cancer
- pulmonary diseases
54
Now many stages of pressure ulcers are there
4
55
At what stage is a pressure ulcer:
Non blanchable erythema
Appears red
Stage 1
56
At what stage is a pressure ulcer:
Full thickness skin loss
Full thickness pressure ulcer extending into the subcutaneous tissue and resembling a crater
Stage 3
57
At what stage is a pressure ulcer:
Partial thickness skin loss
Partial thickness skin erosion
Stage 2
58
At what stage is a pressure ulcer:
Full thickness/tissue loss
Full-thickness pressure ulcer extending into the supportive tissue, muscle, tendon, bone
Stage 4
59
Levels of edema gradient (4)
- Trace
- mild
-Moderate
- severe
60
What level Edema gradient is:
Slight indentation
Level 1
61
What level Edema gradient is:
4 mm indent, rebounds after a few seconds
Level 2
62
What level Edema gradient is:
Deep pitting (6mm), 30 seconds rebound
Level 3
63
What level Edema gradient is:
Very deep, 8mm, more than 30 seconds
Level 4
64
What is the ABCDE skin assessment used for?
suspicious lesions
65
What does the A stand for in the skin assessment
Asymmetry
66
What does the B stand for in the skin assessment
Border irregularity
67
What does the C stand for in the skin assessment
Color
68
What does the D stand for in the skin assessment
Diameter
69
What does the E stand for in the skin assessment
Elevation and enlargement
70
What does the F stand for in the skin assessment
Funny looking
71
Freckles on the dorsal of the hands
Senile Lentignes
72
Confluent lesion
Running together
73
Gyrate shaped lesion
Ring shaped
74
Target shaped lesion
Centered
75
Multiple circles (lesions)
Polycyclic
76
Vesicle seen in chicken pox
Zosterform
77
Herpes zoster known as
Shingles
78
A small hole made by a sharp object
Puncture
79
4 wound types
- Abrasion
- laceration
- puncture
- avulsion
80
Scrape of the skin due to something abrasive
Abrasion
81
A deep cut or tearing of your skin caused by items like knives, tools, machinery
Laceration
82
A wound that occurs when tissue is separated from the body
Avulsion
83
5 ways to prevent skin breakdown
-Nutrition
- repositioning
- Increased mobility/activity
- clean skin
- self assessment
84
Ecchymosis
Bruising
85
unstagable pressure ulcer
Base of ulcer covered by slough and /or eschar in wound bed
86
What increases skin breakdown? ( 5)
- Poor nutrition
- pressure
- moisture (maceration)
-Immobility
- age
87
Viral infection affecting peripheral nerves
Herpes zoster (shingles)
88
Risk factors for pressure ulcers (4)
-Impaired mobility
- Decreased feeling
-Infection
- poor nutrition
89
An unhealthy paleness of the skin
Pallor
90
Redness of the skin due to capillary dilation
Fever, infection, inflammation
Erythema
91
Which abnormal skin color should a nurse anticipate assessing on a dark skinned patient
Ashen gray
92
Lesion that is distinct, individual lesion that remains separate (skin tag)
Discrete lesion
93
Lesion: A scratch, streak, time, or stripe.
Linear lesion
94
Linear arrangement along a unilateral nerve route
Zosteriform lesion
95
Annular lesions that grow together
Polycyclic lesion
96
Flat, colored spot on the skin (ex. Freckle)
Macula
97
Raised red skin lesson due to interstitial fluid (mosquito bite, allergic reaction)
Wheal
98
Solid, elevated mass, less than 1 cm diameter ( mole, wart)
Papule
99
Large mass with serous fluid
Vesicle /bulla
100
Lesion less than 0.5cm (varicella, herpes simplex,)
Vesicle
101
Lesson greater than 0.5 cm ( poison lay, blisters )
Bulla
102
Discoloration due to increasing capillary fragility in old people
Senile pupura
103
What causes gray hair
Functioning melanocytes decrease
104
Why does skin fold and sag in older adults
Loss of elasticity
105
Why is wound healing slower in older people
Cell replacement is slower
106
Where is generalized pallor found ?
Mucous membranes,lips, nail beds
107
Ease of skin to rise
Mobility
108
Ability of skin to return to place when released
Turgor
109
Freckles, liver spots, hyperpigmentation
Seen on forearms and dorsa of hands
Senile lentigines
110
Abnormal dryness of skin
xerosis
111
Skin lesion more than 1 cm
macule
112
Flat Skin lesion more than 1 cm
Patch
113
Secondary skin lesions (2 types)
-Debris on skin surface
- break in continuity of skin surface
114
2 types of debris on skin surface
- Crusts
- scales
115
What causes a false low bp (2)
-Cuff too large
- arm above heart
116
What causes a false high bp? (4)
-Anxiety
- Cuff too small
- cuff too loose
- arm not supported
117
Where to do the skin turgor test
Inferior to the clavicle
118
Pinpoint purple or red spots from small hemorrhages under the skin
Petechiae
119
Steps of checking skin turgor
1. Pinch a large fold of skin between your thumb and forefinger
2. Note the ease with which you were able to move the clients skin
3. Open the pinch and release skin
4. Note now quickly the skin returns feat to position on chest
120
What lesion is this
Annual (circular)
121
What lesion is this
Confluent
122
What lesion of this
Discrete
123
What lesion of this
Gyrate
124
What lesion is this
Grouped
125
What lesion is this
Linear
126
What lesion is this
Target
127
What lesion is this
Zosteriform
128
What lesion is this
Polycyclic
