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PN3 > Test 2 > Flashcards

Test 2 Flashcards

1
Q

How do you check for homans sign?

A

To asses for DVT, client forcefully dorsiflexes the foot. If pain is present, it may indicate a positive result. Warm tender reddened hardened area of calf indicates thrombophlebitis.

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2
Q

Some is normal as lubricant to help pump effectively. If excess fluid, it is called pericardial effusion S1 and S2 will be muffled and hard to hear because of the fluid.

A

Fluid in pericardial space

Cardiac tamponade

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3
Q

Discharge teaching for thombrophelbitis

A

Anticoagulant such as Coumadin. Drink 2-3 quarts of h2o daily

Do not cross legs, elevate legs while sitting, avoid sitting or standing long periods, wear support, shift weight back and forth or circulation. Notify PCP ASAP if assumed DVT or PE.

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4
Q

This is used for the function of

Sensory, protection, maintain fluid and electrolytes

(Protect body from harmful microorganisms, keep in fluid and electrolytes, maintain body temperature)

A

Function of skin

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5
Q

Causes of dysrhythmias?

A

CAD, HF, MI. Asymptomatic or MI. Syncope, fatigue, decreased energy, dyspnea, angina, palps

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6
Q

Carbuncle causes?

A

(An infection) Diabetes, obesity, malnourished, poor hygiene , infect d hair follicle

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7
Q

Nursing diagnosis for burn patients ?

A

Maintain body alignment with splints , not circulation, promote healing, dressing changes, debridement, restore function, pain levels , abx, surgery, infection control and fluid loss

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8
Q

What to know about latex allergy?

A

Avoid latex? Cross reactivity in bananas , avocados, chestnuts, kiwi

Use latex free cart- careful with gloves and tip of vials

Document allergy and report to surgeon

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9
Q

Assessment of pallor ?

A

Lower conjunctival sac, tip and dorsum of tounge of tounge, soft palate, nail beds, palm or plantar creases, skin

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10
Q

Treatment of V-fib?

A

Defibrillation and CPR

Oxygen, amiodarone (cordarone) given through IV, lidocaine hydrochloride, mag sulfate, can also be cardioverted if peripheral pulses are present or defib if peripheral pulses are absent

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11
Q

Lack of blood

A

Anemia

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12
Q

PTT on heparin

A

Partial thromboplastin time. Serum test the identifies abnormalities in clotting pathway.

Normal time is 60-70 sec clot time. If >100 higher clot risk. If taking heparin, do PTT test 30-60 mins before dose

Heparin will prolong PTT

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13
Q

Placement of defib pads ?

A

Right sternum below clavical at apex of heart.
Lubed with gel as done by cardiac doc or nurse.
Everyone should stand clear to prevent shock.

(Left lower infra-scapular region chest )?

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14
Q

Function of platelets in body?

A

The primary function is to prevent bleeding and clot blood

Nonnucleated cells, granular ovoid , or spindle shapes cell fragments.

Thromboplastin clots in needed areas

Secret prostaglandins and serotonin which vasoconstrict.

Fibrin is formed and seals opening.

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15
Q

HR lower than 60.

Causes include myocardial ischemia, electrolyte imbalances, vagaries stim, beta blockers , drug toxicity, intracranial tumors, sleep, vomiting.

Treatments:

A

Bradycardia

  • atriphine , pacemaker , athletes usually not treated
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16
Q

Nursing care for someone with immune deficiency?

A

Asses for infection, fever white patches in oral cavity, adenopathy , persistent diarrhea, frequency, urgency , pain with urination , redness, drainage, swelling of skin.

Monitor labs, sputum, urine , CBC, vitals

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17
Q

Diet for A-fib?

A

Liquid diet , low fat, low cholesterol, low sodium diet.

Eat frequent small meals

Avoid caffeine, fatty foods, and extremely hot or cold foods

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18
Q

People with A-Fib are 5 times for likely to get what?

A

A stroke

this is why they are often in anticoagulants

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19
Q

Inflammatory condition of the skin where the skin reacts to external irritants such as harsh chemicals like detergents or insecticides, allergens like cosmetics, metals such as nickel , mechanical irritation from wool or glass fibers, body substances like urine or feces.

(Itching (puritis), burning , redness)

A

Contact dermatitis

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20
Q

How to treat contact dermatitis

A

Corticosteroid ointment

Oral antihistamines such as Benadryl

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21
Q

Pacemaker discharge teaching to client?

A

Teach client to take accurate apical and radial pulses

Inform client to report dizziness, fainting , or fever

Regular pacemaker checks or trans telephonic monitoring

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22
Q

Treatment for tachycardia?

A

Depends on cause

Calcium channel blockers, beta blockers , anti arrhythmic meds, pacemaker / cardioversion

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23
Q

A chronic progressive, incurable autoimmune disease affecting multiple body organs.

Occurs most commonly in in women during childbearing years and African American women.

A

SLE ( Systemic lupus erythematosus)

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24
Q

Tests for lupus ?

A

THere is no single test for lupus

Molar rash (over checks ), Photosensitivity, oral ulcers, arthritis , seizures , false positive syphilis test

Reduced sodium , avoid direct sunlight , eat healthy diet

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25
Q

Bleeding problem where there is a lack of clotting factors. Inherited

A

Hemophilia

26
Q

What does pain with hemophilia indicate?

What to do / take for pain?

A

Hemarthorosis - bleeding into joints causing pain redness swelling and fever

Don’t take anti inflammatories or aspirin. Take acetaminophen

Use soft bristled tooth brush and electric razor

Avoid contact sports and wear long sleeves

Wear med tag

27
Q

What is pediculosis?

A

Head lice

28
Q

Attach to hair shaft or seams of clothes , have grey pearly appearance. Resembles a tiny crab.

Bite causes severe Pruritis.

Permethrin lotion applied topically

A

Lice

29
Q

What can alter wound healing ?

A

Low hemoglobin levels, hemocritt levels , RBCs, NSAIDs

30
Q

Older population at risk for ?

A

Atrial fibrillation As a result of CAD, heart failure, hypertension

Immunocompromise disease such as tuberculosis HIV

Respiratory acidosis when taking narcotics

Respiratory distress, COPD, respiratory failure , seasonal illness , pneumonia, influenza

31
Q

What does DIC stand for ? And what is it ?

A

Disseminated intravascular coagulation

A condition of altering clotting and hemorrhaging

that stimulates the clotting mechanism causing many very small clots to block arteries and capillaries / Attempt to stop the clot information and causes hemorrhaging which can be a fatal condition

32
Q

A syndrome that Can occur because of diseases such as burns, acute leukemia, metastic cancer, polycythemia Vera , pheochromocytoma, shock , acute infections, septic abortion, abrupto placenta , blood transfusion reactions , and trauma.

It is a condition of altering clotting and hemorrhaging

A

DIC

33
Q

How is DIC treated ?

A

It is treated by Administering her blood or blood products to normalize the clotting factor level

Platelets and packaged red cells are given to replace those lost during hemorrhaging. Plasma is given to normalize clotting factor levels.

34
Q

What to ask patient with bee stings?

A

first determine whether the pt has a hx of allergic reactions and if they carry an epinephrine kit

Ask yes or no questions???

35
Q

What to do for a DVT patient that is on bed rest?

A

Omg they improve - below the knee compression stockings are recommended.

Best rest is recommended in early stages to prevent clot from dislodging and clotting - elevate legs later - never massage because clot could dislodge

Drink 2 to 3 quarts of water per day, do not sit with legs crossed, elevate both legs when sitting, avoid sitting or standing for long periods of time, wear support hose, when standing shift wait frequently and occasionally stand on tiptoes to stimulate the calf muscles to pump blood, notify the doctor is like pain tenderness or swelling or difficulty breathing or chest pain is occurring. To prevent stay ambulatory and deep breathing

36
Q

Narrowing of the heart valve opening that blocks blood flow from the left atrium to the left ventricle.

Usually results from rheumatic fever, but infants can be born with it. Doesn’t cause symptoms unless severe.

IV drugs use, immunosuppressed, dental caries , abscesses, hx of heart disease

A

Mitral stenosis

37
Q

A massive release of inflammatory mediators such as histamine, prostaglandins causing hypersensitivity reaction when allergen comes in contact with the body through ingestion, skin contact, or inhalation

A

Anaphylactic shock

38
Q

Treatment for anaphylactic reaction?

A

Restore fluid volume by blood transfusion and IV hydration, oxygen , sodium chloride to normalize electrolytes

Meds - epinephrine, norepinephrine , phenylalanine, dobutamine , dopamine. Are he most commonly used (vassopressors ) help reduce vasoconstriction

39
Q

Inflammatory disease that occurs 2 to 3 weeks after improper treated pharyngitis Caused by streptococcus

Symptoms are mild fever, probably arthritis, carditis, courier, and rash.

The endocardium, myocardium, and epicardium can be inflamed and leave damage to the mitral valve

Non contagious Fever/disease that commonly affects young people with inflammation of and pain in the joints that often results from strep throat or scarlet fever infection

A

Rheumatic fever

40
Q

Red blood cells with patients - what to report?

A

? Hemocrit , iron , oxyhemoglobin, methemoglobin , caroxyhemoglobin

41
Q

Immunosuppressive medication adverse reaction?

A

Make the client more prone to infections and cancers

42
Q

What is an auto immune disorder and what types are there ?

A

When the body identifies it’s own cells as foreign, so then the body tries to destroy them

Rheumatoid arthritis, systemic lupus, myasthenia Gravis

43
Q

Effects of skin with aging?

A

Blood flow to the skin is reduced

Skin becomes thinner and more easily injured

Loss of skin tissue can cause sagging and wrinkles, sweat glands diminish , which result in dry skin and decreased ability to adapt to temperature

Skin cancer is more common

Number of hair follicles and growth of nails decrease

Age spots

Hyperthermia hypothermia

Grey hair from lack of melanin production

44
Q

Treatment for burn patient ?

A

Oxygen, fluid, electrolytes, chest X-ray, pain control , cleansing of wound or debridement

Skin graft ( auto graft, homo graft, hetero graft, artificial skin graft )

Calories and high protein diet

45
Q

Symptoms in burn patients

A

Hypovolemic shock ( a life threatening condition caused by loss of blood and fluids)

Infection

Damage to respiratory tract, respiratory tract damage includes facial Burns, singed nasal hairs, changes in the boys, difficulty breathing, wheezing, coughing, carbon tinged sputum

High level of carboxyhemoglobin in blood (O2 is not being delivered to vital body tissues)

46
Q

Types of burns :

Epidermis -Red dry skin-

Epidermis and dermis -Blistered moist pink or red skin-

Down to subcutaneous tissue- charring, skin black, brown, red -

Down to muscle and bone - charring skin white to black with networks of thrombosed capillaries

A

First degree, Superficial

2nd°, partial thickness

3rd°, full thickness

4th°, full thickness

47
Q

Blood transfusions what solution can be used ?

A

0.9% normal saline (sodium chloride) can be used with a blood product

Stop if itching rash or fever occur

48
Q

What how long should a nurse observe client for a transfusion reaction After first starting it?

A

Vitals are taken before infusion ,15 minutes and every hour while blood is infusing and at completion

Closely observed the client for a transfusion reaction within the initial 15 minutes

And monitor vitals every 15 minutes for 4 hours

49
Q

Diet for wound healing?

A

increased amounts of calories, protein, vitamins A and C, and sometimes the mineral zinc.

50
Q

What can alter wound healing in some one ?

A

Deficiency in protein, Low HGH, diabetes, rheumatoid arthritis, vascular arterial disease, zinc deficiency, B 12 deficiency, medications such as NSAID’s, corticosteroids, immunosuppressive’s, anticoagulants

51
Q

MI/heart attack treatment

A

Depends on the severity

Lifestyle changes, cardiac rehab, medications such as blood thinners, heart meds, beta blockers, Statin, ace inhibitors, stents, bypass surgery

52
Q

Burns and effect on survival?

A

?

20 % of Body burn can survive

15% or more with infant or elderly may not survive

53
Q

Impaired skin/ infection / best action for nurse ?

A 
?
ABCs
Ask pain level 
Assist to comfort and elevate extremities 
Administration of analgesics as ordered

High protein foods, vit A, C, zinc, copper
Snacks between meals

54
Q

This is the most commonly used test to monitor heparin therapy

1.5-2.5 the normal value

A

APTT

55
Q

Who is priority to prevent infections ?

A

Burn patients and immunosuppressed pts

56
Q

Burn admit chance of survival ?

A

If burns are on head, chest, upper back it usually means lung damage.

Location could indicate chance of survival

57
Q

Most common type of anemia

When body doesn’t have enough iron to synthesize hgb

Diet-

A

Iron deficiency anemia

High in iron and increase vit c

58
Q

Bone marrow decreases it stops functioning

Treatment -

A

Aplastic anemia

Bone marrow transplant

59
Q

Auto immune disease in which parietal cells are destroyed and the gastric mucosa atrophies

Treatment

A

Pernicious anemia

Topical anesthetics

60
Q

Destruction of RBCs , iron and hemoglobin is released

A

Hemolytic anemia

61
Q

Genetic disorder has abnormal hemoglobin S rather than hemoglobin A in RBCs

A

Sickle cell anemia

62
Q

Factors that affect wound healing

A 
Age
Oxygen 
Smoking
Drugs
Obesity
Diseases

PN3 (4 decks)

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