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Basic Nursing Skills (LVN) > Unit 3 Review (Exam 2) > Flashcards

Unit 3 Review (Exam 2) Flashcards

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1
Q

What are Vital Signs?

A

Known to be the first place to discover what is wrong with your patient.

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2
Q

5 Types of Vital Signs

A 
T - Temperature
P - Pulse
R - Respiration
BP - Blood Pressure
P - Pain
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3
Q

Temperature is controlled by which part of the brain?

A

Hypothalamus

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4
Q

Average Adult Temperature

A

98.6

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5
Q

Factors that Influence Body Temperature

A
  • Age
  • Gender
  • Exercise and Activity
  • Time of Day
  • Emotions
  • Illness
  • Drugs
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6
Q

Pyrexia, Febrile, Afrebrile are all known as ____?

A

Fever

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7
Q

HYPERthermia

A

High tempterature; Up to 105.8 degrees

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8
Q

HYPOthermia

A

Low temperature; 95 degrees and below

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9
Q

True/False: You should check vitals before giving meals.

A

TRUE

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10
Q

True/False: You should check vitals when a patient is complaining.

A

TRUE

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11
Q

True/False: You should check vitals before/after surgery.

A

TRUE

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12
Q

True/False: Newborns & Elderly have the most trouble getting temperature.

A

TRUE

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13
Q

Signs & Systems of Fever

A
  • Flushed skin
  • Warm to touch
  • Thirst
  • Restless and Irritable
  • Poor Appetite
  • Glassy Eyes
  • Increased perspiration
  • Headache
  • Elevated pulse and respiration
  • Disorientation and confusion
  • Convulsions
  • Fever Blisters
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14
Q

Phases of Fever

A
  • Prodromal Phase
  • Onset Phase
  • Stationary Phase
  • Resolution Phase
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15
Q

Signs & Symptoms of Subnormal Temperature

A
  • Pale, cool skin
  • Listlessness
  • Decrease pulse and respirations
  • Decreased ability to solve problems
  • Diminished ability to feel pain and other sensations
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16
Q

What are the 4 sites for taking temperatures?

A
  • Oral
  • Rectal
  • Axillary (under arm)
  • Tympanic
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17
Q

What are the 4 assessment sites?

A
  • Oral
  • Rectal
  • Axillary
  • Ear
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18
Q

Types of Thermometers

A
  • Glass
  • Electronic
  • Infrared (tympanic)
  • Chemical
  • Digital
  • Automated Monitoring Devices
  • Continuous Monitoring Devices
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19
Q

Define Pulse

A

The sensation felt a the heart forces blood into the arteries walls to expand and distend.

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20
Q

Define Pulse/Heart Rate

A

The number of pulsations palpated in 1 minute.

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21
Q

Factors that Influence Pulse Rates

A
  • Age
  • Circadian Rhythm (fast during the day, slow at night)
  • Gender
  • Body Build
  • Exercise and Activity
  • Stress and Emotions
  • Elevated Body Temperature
  • Blood Volume and Components
  • Drugs
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22
Q

What is the average adult pulse?

A

80

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23
Q

What is Tachycardia?

A

Fast Heart Rate (100-150 bpm)

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24
Q

What is Bradycardia?

A

Slow Heart Rate (Less than 60 bpm)

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25
Q

What is Dysrhythmia?

A

Irregular Heart Rate

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26
Q

What is Arrhythmia?

A

Pattern of pulsations and pauses (normal heart rate)

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27
Q

What is Pulse Volume?

A

The quality of pulsations

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28
Q

What are the 5 pulse volumes?

A
  • Absent (No Pulse)
  • Thready (Faint to No Pulse)
  • Weak (Light Pulse)
  • Normal (Pulse is present and clear)
  • Bounding (Strong Pulse)
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29
Q

What are the 8 Pulse Sites?

A
  • Temporal (Temple)
  • Carotid (Neck)
  • Femoral (Pelvic Region)
  • Doralis Peds (Foot)
  • Brachial (Bicep Region)
  • Radial (Wrist)
  • Popliteal (KneeCap)
  • Posterior Tibal (Back Foot)
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30
Q

When taking a pulse, count for ____ seconds, and multiply times ____.

A

30 seconds; x 2

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31
Q

What pulse is the most accurate pulse?

A

Apical

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32
Q

Where is the apical pulse located?

A

Midclavicular, 5th Intercostal Space

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33
Q

How do you calculate a Pulse Deficit?

A

Apical Pulse Rate (-) Radial Pulse Rate

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34
Q

What is Respiration?

A

Exchange of oxygen and carbon dioxide.

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35
Q

What is Tachypnea?

A

Fast respirations

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36
Q

What is Bradypnea?

A

Slow respirations

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37
Q

What are Adventitious Lung Sounds?

A

Abnormal lung sounds.

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38
Q

What is Blood Pressure?

A

Force exerted by blood within the arteries.

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39
Q

Why do we check blood pressure?

A

To assess the efficiency of the heart.

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40
Q

What is Systole?

A

Working phase of the heart; heart contracts.

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41
Q

What is Diastole?

A

Resting phase of the heart; heart relaxes and refills.

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42
Q

How is Blood Pressure written?

A

As a fraction.

Systolic/Diastolic

43
Q

What is the average adult blood pressure?

A

120/80

44
Q

What is Arterio/sclerosis?

A

Arteries lose elasticity.

45
Q

What is Athero/sclerosis?

A

Arteries become narrowed w/ fat deposits.

46
Q

What is Hypertension?

A

High Blood Pressure; 140/90 bpm

47
Q

What is Hypertension?

A

Low Blood Pressure; 96/60 bpm

48
Q

How do you calculate Pulse Pressure?

A

Systolic BP (-) Diastolic BP = Pulse Pressure

49
Q

What equipment is needed to check blood pressure?

A
  • Stethoscope
  • Sphygmomanometer
  • Read the meter at eye level
  • Maintain the arm at the level of the heart.
50
Q

Who admit patients to facility?

A

Physicians

51
Q

What are 3 things a Nurse must do when admitting a patient?

A
  • Prepare room
  • Welcome patient
  • Orient Patient (show where everything is)
52
Q

Safegaurding valuables and clothing, helping the patient undress, compiling the data base, having medical admission responsibilities, and providing common responses to admission are all apart of what process?

A

Admission

53
Q

True/False: A patient’s personal values should be sent home when being admitted.

A

TRUE.

54
Q

True/False: If responsible for a patient’s personal values, you should document it, envelope it, label it, provide yours and the patient’s signature and put it in a safe.

A

TRUE.

55
Q

What does it mean when you are discharging a patient?

A

You are in process of releasing them out of the facility.

56
Q

True/False: Discharge begins at admission.

A

TRUE.

57
Q

True/False: You must have discharge orders to discharge a patient.

A

TRUE.

58
Q

What does “Leaving Against Medical Advice” consist of?

A
  • A patient leaving before being discharged
  • When patient is unhappy
  • Negotiating the patient to stay
  • Having the patient sign AMA form
  • Document the “AMA” action.
59
Q

What is needed to complete during Discharge Planning?

A
  • Improve client outcomes
  • Post discharge needs
  • Coordinating community resources
  • Special considerations
60
Q

What are the proper discharge instructions?

A

M.E.T.H.O.D.

61
Q

What does M.E.T.H.O.D. represent?

A 
M - Medication
E - Environment
T - Treatments
H - Health Teaching
O - Outpatient referral
D - Diet
62
Q

What is the proper procedure when discharging a patient?

A
  • Gather belongings
  • Arrange transportation
  • Escorting the Client
  • Writing a discharge summary
  • Terminal cleaning
63
Q

Where are some places patients are transferred?

A
  • Extended Care Facilities
  • Basic Care Facilities
  • Nursing Homes
  • Home Health Care
64
Q

Why do we assess patients?

A

To see a baseline of a patient’s condition.

65
Q

What are the techniques for a Physical Assessment?

A

I - Inspection (observe)
P - Percussion (Tapping/Striking Fingeretips)
P - Palpation (Feel organs)
A - Auscultation (Listen to heart, lungs, abdomen)

66
Q

True/False: Before performing a Physical Assessment on a patient, you must have the room clean, warm, private, and have good lighting.

A

TRUE.

67
Q

What does PQRSTU represent?

A 
P - Provactative, Pallative
Q - Quality, Quantity
R - Region, Radiation
S - Severity
T - Timing
U - Understanding
68
Q

Who performs a Complete Assessment?

A

RN - Registered Nurse

69
Q

Who performs a Focused Assessment?

A

LVN - Licensed Vocational Nurse

LPN - Licensed Practical Nurse

70
Q

As a LVN, what type of approach will you provide during an physical assessment?

A

Head-To-Toe

71
Q

Why is it important to perform a Head-To-Toe assessment?

A
  • Prevents overlooking data
  • Requires fewer positions
  • Takes less time
72
Q

What does Data Collection include during an assessment?

A
  • Head/Neck
  • Chest
  • Extremities
  • Abdomen
  • Genitalia
  • Anus & Rectum
73
Q

What is the purpose of assessing the Head/Neck?

A

To retrieve patient’s mental status

74
Q

What is the main procedure done on eyes during physical assessment?

A

P.E.R.R.L.A

P - Pupils
E - Equal
R - Round
R - Responsive
L - Light
A - Accommodation
75
Q

What test is performed to detect bone conduction during physical assessment?

A

EARS-Weber Test

76
Q

What test is performed to detect air & bone conduction during physical assessment?

A

EARS-Rinne Test

77
Q

What is the purpose of performing a “Skin Turgor” on a patient?

A

Allows the skin to repel back to its original state as it will confirm patient’s hydration status.

78
Q

When assessing skin, what can be determined from a patient with Ecchymosis?

A

Purple, bruised skin.

79
Q

What pattern is performed for a Chest Auscultation?

A

Zig-Zag (10 moves)

80
Q

What are the 4 Normal Lung Sounds?

A
  • Tracheal Sounds
  • Bronchial Sounds
  • Bonchovesicular Sounds
  • Vesicular Sounds
81
Q

What does “Tracheal Sounds” sound like?

A
  • Loud & Coarse
  • Equal
  • Brief Pause
82
Q

What does “Bronchial Sounds” sound like?

A
  • Harsh & Loud
  • Shorter Respiration
  • Pause
83
Q

What does “Bronchovesicular Sounds” sound like?

A
  • Medium Range
  • Equal
  • No Pause
84
Q

What does “Vesicular Sounds” sound like?

A
  • Soft, rustling
  • Longer inspiration
  • No pause
85
Q

What does “Adventitious” mean?

A

Abnormal lung sounds.

86
Q

As a Nurse, what do you assess when a patient’s lung is sounding adventitious?

A

Cough & Sputum

87
Q

What are the 4 Auscultating Heart Sounds?

A
  • Aortic
  • Pulmonary
  • Tricuspid
  • Mitral
88
Q

What is a Capillary Refill?

A

Pressure is applied to nail bed until it is turned white, then blood is removed to tissue after 3 seconds.

89
Q

What is the shape of “clubbed” fingernails?

A

Heart-Shaped

90
Q

What is Edema?

A

Excessive fluid in legs and feet.

91
Q

What are the 5 stages of Edema?

A

+ 1 Pitting = Little fluid present
+2 Pitting = Adequate amount of fluid present
+3 Pitting = larger amount of fluid present
+4 Pitting = Excessive fluid present
+5 Brawny = Leg/Feet extremely enlarged

92
Q

True/False: Pain is the 5th vital sign.

A

TRUE.

93
Q

What is the process of Pain?

A
  • Transduction
  • Transmission
  • Perception (Pain threshold/tolerance)
  • Modulation
94
Q

What is one Pain Theory?

A

Gate Control Theory

95
Q

What are Endogenous Opioids?

A

Natural Morphine-like subtance

96
Q

What are the 5 types of pain?

A
  • Cutaneous (Skin, burning)
  • Visceral (Organs)
  • Neuropathic (Phantom Limb)
  • Acute (Less than 6 mo.)
  • Chronic (6 mo. and longer)
97
Q

True/False: Pain is subjective in nature. Pain assessment looks at onset, quality, intensity, location, and duration.

A

TRUE.

98
Q

What are some assessment tools to detect pain?

A
  • Pain Scale (0-10)

- Pain Scale with descriptive words

99
Q

True/False: Always assess pain before and 30 minutes after administering pain medication.

A

TRUE.

100
Q

When providing drug therapy, you must start ____, and go ____.

A

low; slow

101
Q

What is a placebo?

A

Mind body interactions (addiction)

102
Q

What are Korotkoff sounds?

A

Vibrations of blood within the arterial wall or changes in blood flow.

103
Q

What are the 5 Phases of Korotkoff sounds?

A 
Phase I - Faint Tapping
Phase II - Swishing
Phase III - Loud knocking
Phase IV - Muffled
Phase V - Silence

Basic Nursing Skills (LVN) (4 decks)

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