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nursing funds > week 4 ati-- ch 26 & hw > Flashcards

week 4 ati-- ch 26 & hw Flashcards

1
Q

dyspnea

A

shortness of breath

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2
Q

Kassmaul Respirations

A

abnormally deep & rapid breaths w/ REGULAR ryhthym

**metabolic/diabetic acidosis & kidney disease

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3
Q

Cheyene Strokes

A

IRREGULAR shallow to deep breaths followed w hyperventilation then apnea

*stroke, increased ICP, tumor or heart failure

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4
Q

valsalva maneuver

A

lowers blood pressure & stimulates vagus nerve

*client bears down as if bowel movement

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5
Q

tachycardia
vs
bradycardia

A

tachy: pulse >100
brady: pulse <60

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6
Q

apical pulse

A

heart rate heard @ base of heart
**4th intercostal space (child
**5th intercostal space (adult)

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7
Q

pulse defecit

A

difference between apical pulse & peripheral pulse

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8
Q

Pulse ratings

A

0 = absent
+1 = weak
+2 = normal
+3 = strong
+4 =bounding

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9
Q

Body temp

A

normal= 96.8 -100.4
fever= 100.4+

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10
Q

Respiratory Rates

A

*newborn (birth-28 days) = 30-60

*1mo - 3yrs = 25-30

*3-12 yrs = 20-25

*12-20yrs = 16-20

*20+ = 12-20

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11
Q

eupnea

A

normal breathing

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12
Q

newborn pulse

A

110-160bpm
*birth- 28 days

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13
Q

infant pulse

A

90-160 bpm
*1mo-1yr

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14
Q

toddler pulse

A

80-140
*1-3yrs

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15
Q

preschool pulse

A

70-120
*3-6yrs

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16
Q

school age pulse

A

60-110
*6-12yrs

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17
Q

adolescent pulse

A

50-100
*12-20yrs

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18
Q

adult pulse

A

60-100
*20+yrs

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19
Q

normal blood pressure for toddler

A

systolic: 85-91
diastolic: 37-49
*females slightly higher

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20
Q

normal blood pressure for preschooler

A

systolic= 89-98
diastolic = 46-54
*females higher

21
Q

normal blood pressure for school age

A

systolic: 94-106
diastolic: 55 - 62

22
Q

toddler hypertension

A

systolic: 103+
diastolic: 56+

23
Q

preschool hypertension

A

systolic: 107+
diastolic: 65+

24
Q

school age hypertension

A

systolic: 111+
diastolic: 74 +

25
Q

to diagnose pediatric hypertension

A

healthy BMI & blood pressure at or above 95th percentile for age on 3 separate visits

26
Q

newborn blood pressure

27
Q

Hypertension stages

A

**Elevated
systolic: 120-129
diastolic: <80

**Stage 1
systolic:130-139
diastolic: 80-89

**Stage 2
systolic: 140+
diastolic: 90+

**hypertensive crisis
systolic: 180+
diastolic: 120+

28
Q

cardiac output

A

amount of blood pumped into system within 1 minute
CO= SV x HR

29
Q

stroke volume

A

amount of blood ejected by the ventricle during one contraction

30
Q

pain threshold
vs
pain tolerance

A

THRESHOLD: point at which a stimulus causes the client to perceive pain

TOLERANCE: how much of a stimulus the client is willing to accept

31
Q

nociceptive pain

A

referred pain
*throbbing, aching

32
Q

neuropathic pain

A

nerve pain
*numbness, burning, intense, shooting, & itching

33
Q

negligence
vs
malpractice

A

negligence–failure to act

malpractice—act itself

34
Q

opioid scale

A

S.B.I.R.T

S–screening
B–brief
I–intervention
R–referral to
T–treatment

35
Q

nemonic to assess pain

A

P.Q.R.S.T.

P–precipitating cause
Q– quality
R– region
S–severity
T–timing

36
Q

pain scales for children

A

*Wong Baker FACES scale (age 3+)
*FLACCS Scale (observational 1-5 min awake, 5min+ sleeping)

37
Q

pain scale for neonates

A

CRIES Scale
(0-2pts each category w/ 10pts total)

38
Q

a nurse provides an introduction to a client as the first step of a comprehensive physical exam. Which of the following strategies should the nurse use with this client? (sap)

  1. Address the client w/ the appropriate title & their last name

2.Use a mix of open- & closed- ended questions

  1. Reduce environmental noise
  2. Have the client complete a printed history form
  3. Perform the general survey before the exam
A

2.Use a mix of open- & closed- ended questions

  1. Reduce environmental noise
  2. Perform the general survey before the exam
38
Q

A nurse in a provider’s office is documenting findings following an exam performed for a client new to the practice. Which of the following parameters should the nurse include as part of the general survey? (sap)

  1. Posture
  2. Skin lesions
  3. Speech
  4. Allergies
  5. Immunizations
A
  1. Posture
  2. Skin lesions
  3. Speech
39
Q

a nurse is collecting data for a comprehensive physical exam. After inspecting the client’s abdomen, which of the following skills of the physical exam process, should the nurse perform next?

  1. Olfaction
  2. Auscultation
  3. Palpation
  4. Percussion
A
  1. Auscultation
40
Q

a nurse is preparing to perform a comprehensive physical exam of an older adult client. Which of the following interventions should the nurse use in consideration of the client’s age? (sap)

  1. Expect the session to be shorter than for a younger client
  2. Plan to allow plenty of time for position changes

3.Make sure the client has any essential sensory aids in place

  1. Tell the client to take their time answering questions
  2. Invite the client to use the bathroom before beginning the examination
A
  1. Plan to allow plenty of time for position changes

3.Make sure the client has any essential sensory aids in place

  1. Tell the client to take their time answering questions
  2. Invite the client to use the bathroom before beginning the examination
41
Q

A nurse in a provider’s office is performing a physical exam of an adult client. Which part of the hands should the nurse use during palpation for optimal assessment?

1.Palmar Surface
2. Fingertips
3.Dorsal Surface
4. Base of the fingers

A

Dorsal Surface

42
Q

general survey includes

A
  1. physical appearance
  2. body structure
    3.mobility
  3. behavior
  4. vital signs
43
Q

Abdomen Exam Sequence

A

1.inspect
2.auscultate
3. percuss
4. palpate
**avoids altering bowel sonds

44
Q

Exam Sequence

A
  1. Inspect
  2. Palpate
  3. Percuss
    4.Auscultate
45
Q

dorsal part of the hand feels

A

temperature

46
Q

palm of hand feels

47
Q

direct percussion
vs
indirect percussion

A

direct = touch

indirect = hand flat of surface

48
Q

Fist percussion

A

identifies tenderness over kidneys, liver, & gallbladder

nursing funds (15 decks)

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