Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Practical Nursing 101 > Unit III > Flashcards

Unit III Flashcards

You may prefer our related Brainscape-certified flashcards:
Nursing Mental Health flashcards Nursing Management of Care flashcards NCLEX-PN® flashcards Physics 101 flashcards NCLEX-RN® flashcards Psychology 101 flashcards Chemistry 101 flashcards Nursing Fundamentals flashcards Nursing Pediatrics flashcards Nursing Safety & Infection flashcards
1
Q

Guaiac

A

a test for blood in stool

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Petechaie

A

Pinpoint, round, red, and purple spots on the skin like small blood vessels have popped

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Tinnitus

A

ringing in the ears

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Vertigo

A

dizzy whirling sensation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Peristalsis

A

movement of intestines

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Concave

A

curving inward, sunken

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Convex

A

curving outward, bulging

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Ridged abdomen

A

firm, board like on palpation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

striae

A

stretch marks

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Atrophy

A

underdevelopment or wasting of muscle tissue

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Parts of client interview

A 
o	Establish relationship; build report
o	Client and family history
o	Identify client preferences
o	Individualize care approach
o	Explore all aspects of the whole person (holistic approach)
o	Begin data collection for assessment
o	Use plain language
o	Therapeutic communication
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Therapeutic communication techniques

A 
Active listening Open-ended questions
Clarifying
Back channeling
Probing
Close-ended questions
Summarizing
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Sympathetic nervous system

A
  • Fight or Flight
  • Pupils dilate to see better
  • Bronchial tubes dilate to increase air flow, respiratory rate increases hyper oxygenate.
  • Heart rate increases to oxygenate the body
  • Blood pumps to large muscles to prepare for fight or flight
  • Digestive blood flow decreases due to shift in circulation.
  • Release of hormones; epinephrine and norepinephrine.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Parasympathetic Nervous system

A
  • Cool down phase

* Body systems return to normal

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Signs and symptoms of Stress

A
  • Rapid, shallow breathing (tachypnea)
  • Dry mouth
  • Diaphoresis
  • Shakiness, tremors
  • Restlessness
  • Increased pulse (tachycardia)
  • Muscle tension
  • Rapid Speech
  • Frequent Urination
  • Dizziness
  • Anxiety
  • Irritability
  • Nausea
  • Changes in appetite
  • Feeling of shortness of breath
  • Chest pain or pain in other parts of the body
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

General Adaptation Syndrome Stage 1 Alarm

A

Body functions are heightened to respond to stressors, also called fight or flight response. Hormones are released, which cause elevated blood pressure and heart rate, heightened mental alertness, increased secretion of epinephrine and norepinephrine, and increased blood flow to muscles.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

General Adaptaion Syndrome Stage 2 resistance

A

body functions normalize while responding to the stressor. The body attempts to cope with the stressor and return to homeostasis. Stabilization of blood pressure, heart rate, and hormones will occur.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

General Adaptaion Syndrome Stage 3 Exhaustion

A

Body functions are no longer able to maintain response to stressor and the client cannot adapt. The end of this stage results in recovery or death.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Sources of stress related to hospitalization

A
  • New people
  • Wearing a gown
  • Lack of privacy
  • Dependent on others for food, bathroom, washing
  • Being awakened at all times
  • Too many or not enough visitors
  • Finance cost, family needs, pets at home
  • What will diagnosis be?
  • Medical terms they don’t understand
  • Waiting
  • Underlying mental health condition
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Ways to reduce stress

A
  • Introductions
  • Explanations for everything
  • Orientation
  • LISTEN
  • Therapeutic communication
  • Provide privacy as much as possible
  • Allow independence
  • Hourly rounding
  • Answer call lights promptly
  • Be honest
  • Allow sleep
  • Visitors
  • Address concerns
  • Creature comforts
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

When measuring height…

A 
measure from crown of head to sole of foot
No shoes
Feet together
Back straight
Shoulders back
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

When measuring weight…

A

No shoes

For daily weights: same time of day, best if first thing in the morning, use same scale every day

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Hypothermia interventions

A

COLD BELOW 95

Provide warm environmental temperature

heated humidified oxygen

warming blanket

warmed oral or IV fluids.

Keep head covered.

Provide continuous cardiac monitoring

Have emergency resuscitation equipment on standby

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Hyperthermia Interventions

A

Fever above 102.2
Obtain specimens for blood, urine, or wound cultures as needed

Assess/monitor white blood cell counts, sedimentation rates, and electrolytes

Ensure prescribed cultures are obtained before administering prescribed antibiotics, to promote test accuracy.

Provide fluids and rest–>Minimize activity–> use a cooling blanket

Children and older adults are at risk for fluid volume deficit

Provide antipyretics (aspirin, acetaminophen, ibuprofen). Do not give aspirin to manage fever for children and adolescents who have a viral illness (influenza or chickenpox) due to the risk of Reye’s syndrome.

Prevent shivering, as this increase energy demand.

Offer blankets during chills and remove them when the client feels warm.

Provide oral hygiene and dry clothing and linens

Keep environmental temperature between 21-27 C

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Affect of age on respirations

A

decreases with age

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Men and chilcren are what kind of breathers

A

diaphragmatic breathers; abdominal movements more noticable

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

Women breath using…

A

Thoracic muscles, chest movements are more pronounced

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

An upright body posistion allows chest wall…

A

to expand more fully

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

Amphetamines and cocaine can increase

A

Respiratory rate and depth

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

Opioids, sedatives, bronchodialators, and general anesthetics can decrease…

A

Respiratory rate and depth

Respiratory depression is a adverse reaction

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

An injury to the brain stem can decrease…

A

respiratory rate and rhythm

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

Anemia and high altitudes can cause

A

Impaired oxygen carrying comacity of blood

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

Cheyne-stokes

A

respirations that become faster and deeper, then slower, alternates with periods of apnea.
Indicates end of life

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

Kussmaul’s

A

Faster and deeper respirations without pauses.

Indicated end of life

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

Retractions

A

muscles of the chest wall/abdomen moving inward with inhalation, cue to work of breathing.
Can occur in children and newborns

36
Q

Nasal Flaring

A

Widening of nostils

cue to hypoxia

37
Q

Cyanosis

A

blue discoloration of the skin/mucous membranes

Cue to Hypoxia

38
Q

COPD normal SpO2

A

85-89%

39
Q

Oxygen can require what type of monitoring

A

continuous or intermitten

40
Q

Hypercapnia

A

increased carbon dioxide

41
Q

If using oxygen no…

A 
smoking
petroleum products (chap stick)
42
Q

How to assess orthostatic blood pressure

A

take pt’s BP and HR after the pt has been in the supine position for 3-10 mins. Next, have pt change to the sitting or standing position and immediately reassess BP and HR. Wait an additional 3 mins and repeat BP and HR. The pt has orthostatic hypotension of the SBP decreases more than 20 mmHg or the DBP decreases 10 mmHg or more with increase in HR.
DO NOT DELEGATE.

43
Q

S3, S4, Gallop

A

extra heart sounds

abnormal

44
Q

Murmurs

A

blowing or swishing sound heard over heart, best heard with bell of stethescope.
abnormal

45
Q

Thrills

A

Vibration you can feel
rare
accompany murmurs or other abnormalities

46
Q

Bruits

A

blowing/swishing sounds heard over blood vessels, listen with the bell
abnormal

47
Q

Cardiac changes with aging

A

Systolic hypertension

Point of maximum impulse becomes more difficult to palpate because AP diameter of chest widens

Coronary blood vessel walls thicken and become more ridid with narrowed lumen

Cardiac output decreases and strength of contraction leads to poor activity tolerance

Heart valves stiffen due to calcification

Left heart ventricle thickens

Pulmonary vascular tension increases

Systolic blood pressure rises

Peripheral circulation diminishes

48
Q

When assessing lung sounds…

A

always listen directly on skin

49
Q

Bronchial

A

Normal

Medium pitched blowing sounds
heard over trachea

expiration longer than inspiration

50
Q

Bronchovesicular:

A

Normal

medium pitched blowing sounds, heard over bronchial tubes and bronchioles, expiration equal to inspiration.`

51
Q

Vesicular

A

Normal

soft, low pitched, heard over peripheral areas of the lungs, inspirations longer than expiration.

52
Q

Crackles/rales

A

Abnormal

fine to coarse bubbly sounds, rice krispies sound, indicates fluid. Can be cleared up with coughing.

53
Q

Wheezes

A

high pitched musical sounds, indicates airway constriction or obstruction.

54
Q

Stridor

A

high pitched barking sounds, indicates more emergent airway construction or obstruction.
Indicative of croup

55
Q

Rhonchi

A

coarse, low pitched rumbling sounds, indicates fluid of mucous.

56
Q

Pleural Friction RUb

A

dry grating, or rubbing sound, indicates inflammation at the lung lining, can be painful.

57
Q

Absence of breath sounds in presence of respirations indicate…

A

collapsed or punctured lung; absence of lung lobe due to surgical collapse.

58
Q

Expected changes in lung sounds with age

A

o Chest shape changes so that the AP diameter becomes similar to the traverse diameter (barrel chest), resulting in decreased vital capacity.
o Chest excursion or expansion diminishes
o Cough reflex diminishes
o Cilia ineffectively removes dust and irritants from the airways.
o Alveoli dwindle, airway resistance increases, and the risk of pulmonary infection increases.
o Kyphosis

59
Q

Kyphosis

A

an increased curvature of the thoracic spine due to osteoporosis and weakened cartilage, results in vertebral collapse and impairment of respiratory effort.

60
Q

Neuropathic pain

A

related to a dysfunction of the nervous system, can often be burning, numbness/tingling, dull, heavy pressure.

61
Q

Phantom Pain

A

pain after the loss of a body part where the body part would be.

62
Q

Pain threshold

A

point at which person feels pain

63
Q

Idiopathic pain

A

form of chronic pain without a know cause and pain exceeds typical pain levels

64
Q

Pain Assessment

A 
Intensity
Location
TIming
Aggrivating factors
Accompanying symptoms
65
Q

When a client is in pain alway…

A

Convey acceptance
caring
monitor vital signs

66
Q

Pharmacological Pain management methods

A 
Opioids
Nonopioids
Adjuvant
Patient-controlled analgesia
Pain patch
67
Q

Non-pharmacological treatents

A 
relaxation techniques
Electrical nerve stimulation
distraction
Imagery
massage
Acupuncture/acupressure
Binders/braces
Hydrotherapy
Hypnosis
PHysical therapy
Heat/cold
68
Q

Normal Capillary refill is…

A

3 seconds

69
Q

If capillary refill is 3 seconds…

A

repeat on another digit first

70
Q

Pupillary abnormalities may indicate

A

head trauma
increased pressure inside the skull
Always check respiratory status first–> Respiratory status is also affected by increased pressure in the skull

71
Q

Active ROM

A

individual can actively move limbs

72
Q

Passive ROM

A

Individual cannot actively move, limbs must be moved by another person.

73
Q

Otunded

A

Client responds to light shaking but can be confused and slow to respond

74
Q

Stuporous

A

the client requires painful stimuli to achieve a response; client may not be able to verballt respond

75
Q

Glasgow coma scale

A

from 3(comatose) to 15 (alert)

76
Q

When assessing the abdomen

A

Inspection, ascultation, palation

77
Q

WHen ascultating the abdomen

A

RLQ–>RUQ–>LUQ–>LLQ

78
Q

Normoactive bowel sounds

A

5-30 clicks/gurgles in 2 mins

79
Q

Hypoactive bowel sounds

A

5 clicks/gurgles in 2 minutes

80
Q

Hyperactive

bowel sounds

A

greater than 30 clicks/gurgles in 2 minutes or rumbling

81
Q

Age considerations for elderly

A

o Allow more time for response, greater store of knowledge
o Allow for periods of rest or breaks if needed
o Do not stereotype: not all elderly require assistance, etc.
o Allow for independence to the extent possible

82
Q

Age considerations for Pediatrics

A

o Separation anxiety  allow parent to hold child during assessment
o Stranger Danger
o Language barrier
o Fear  Allow familiar object like blanket, toy, etc.
o Demonstrate assessment, ask permission

83
Q

Age considerations for Adolescents

A

o Independence: allow for choices, ask permission
o Privacy: allow to decide if parent present if possible
o Personal space

84
Q

Endocrine System disorders

A

Insomnia
apnea
snoring
narcolepsy

85
Q

When usig a pain patch…

A

applied to skin
Monitor confused/psychotic patients closley
Do not touch with bare skin WEAR GLOVES
Do not cut

Practical Nursing 101 (10 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions