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Nursing is recognized increasingly as a profession based on __________. - Correct Answer-* Well-defined body of specific and unique knowledge. * Strong Service Orientation. * Recognized authority by a professional group. * Code of Ethics. * Professional organization that sets standards. * Ongoing research. * Autonomy and self-regulation. Activities to restore health focus on _______. - Correct Answer-The individuals with illness and range from early detection of a disease to rehabilitation and teaching during recovery. Examples.) Drug rehabilitation, teaching patients how to administer their medication, and range of motion exercise for patients. Purpose of the ANAs Nusrsing Social Policy Statement? - Correct Answer-It describes: *The social context of nursing. *The definition of nursing. *The knowledge base for nursing practice. *The scope of nursing practice. *The regulation. *Standards of professional nursing practice.
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Nursing is recognized increasingly as a profession based on __________. - Correct Answer-* Well-defined body of specific and unique knowledge.
__________ allow nurses to carry out professional roles, serving as protection for the nurse, the patient, and institution where health care is provided. - Correct Answer- Standards Licensure - Correct Answer-The legal authority to practice as a nursing professional. How do nurses gain knowledge, skills, and critical thinking? - Correct Answer-* Cognitive Skills
Tonus - Correct Answer-Is the term used to describe the state of slight contraction. The usual state of skeletal muscle. A patient who is on complete bed rest can can develop Tonus. Contractures - Correct Answer-Permanent contraction of a muscle. If bed rest is prolonged, a patient can develop Contractures. Negative Nitrogen Balance - Correct Answer-Disease characterized by a larger breakdown of protein than that which is manufactured. Results in muscle wasting and decreased physical energy for movement and work. Exercise - Correct Answer-Active exertion of muscles involving the contraction and relaxation of muscle groups. Isotonic Exercise - Correct Answer-Involves muscle shortening and active movements. Examples.) Carrying out ADLs, Swimming, Walking, and Bicycling. Isokinetic Exercise - Correct Answer-Involves muscle contractions with resistance. Examples.) Rehabilitation exercise for knee and elbow injuries, and weight lifting. Isometric Exercise - Correct Answer-Involves muscle contraction without shortening. Examples.) Contractions of quadriceps and gluteal muscles. (Holding a Yoga Pose) Osteoporosis - Correct Answer-The process of bone demineralization. Exercise has been know to help prevent osteoporosis. Atrophy - Correct Answer-Decreased muscle size caused by immobility. Ankylosis - Correct Answer-A consolidation and immobilization of a joint caused by immobility. Range of motion - Correct Answer-The maximum degree of movement of which a joint is capable. Flaccidity - Correct Answer-Increased tone that results from disuse or neurologic impairments, and is described as a weakness or paralysis of the involved area. Spasticity - Correct Answer-Increased tone that interferes with movement that is caused by neurologic impairments, and is often described as stiffness, tightness, or pulling of the muscle. Paresis - Correct Answer-Impaired muscle strength or weakness. Paralysis - Correct Answer-The absence of strength secondary to nervous impairment.
Footdrop - Correct Answer-The foot is unable to maintain itself in the perpendicular position, heal to gait is impossible, and the patient experiences extreme difficulty in walking. Active Exercise - Correct Answer-The patient independently moves joints through their full range of motion. (Isotonic Exercise) Passive Exercise - Correct Answer-The patient is unable to move independently, and the nurse moves each joint through its range of motion. Dangling - Correct Answer-Refers to the position in which the person sits on the edge of the bed with legs and feet over the side of the bed. Factors Affecting Movement and Alignment - Correct Answer-* Growth and Development
Perspective on health during WWII - Correct Answer-Large numbers of women began to work outside the house. Created the need for more nurses. Upgraded nursing education. Perspective in Nursing today - Correct Answer-Huge growth of nursing profession. Technical advancements. Competitive. Customer Service. _________ had a vision from God to become a nurse. - Correct Answer-Florence Nightingale Contributions of Florence Nightingale. - Correct Answer-* Identified personal needs of patients and role of nurse in meeting them.
2.) Rock your pelvis out on the side of the patient. 3.) Grasp the gait belt. 4.) Pull the weight of the patient backward against your body. 5.) Gently slide patient down to the floor, protecting her head. 6.) Stay with the patient and call for help. What is the procedure for log-rolling a patient? - Correct Answer-1.) Have the patient cross the arms on the chest and place a pillow between the knees 2.) Have two nurses stand on one side of the bed opposite the direction the patient will be turned with the third helper standing on the other side and if necessary, a fourth helper at the head of the bed to stabilize the neck. 3.) Fanfold or roll the drawsheet tightly against the patient and carefully slide the patient to the side of the bed toward the nurses. 4.) Have one helper move to the other side of the bed so that two nurses are on the side to which the patient is turning. 5.) Face the patient and have everyone move on a predetermined time, holding the drawsheet taut to support the body, and turn the patient as a unit toward the two nurses. A nurse is caring for an 82-year-old woman in a long-term care facility who has had two urinary tract infections in the past year related to immobility. Which finding would the nurse expect in this patient? A.) Improved renal blood supply to the kidneys. B.) Urinary Stasis. C.) Decreased urinary calcium. D.) Acidic urine formation. - Correct Answer-B.) Urinary Stasis. In a non-erect patient, the kidneys and ureters are level. In this position, urine remains in the renal pelvis for a longer period of time before gravity causes it to move into the ureters and bladder, resulting in urinary stasis. Urinary stasis favors the growth of bacteria that may cause urinary tract infections. Regular exercise improves blood flow to the __________. - Correct Answer-Kidneys A nurse is caring for a 73-year-old male patient who is hospitalized with pneumonia and is experiencing some difficulty breathing. The nurse most appropriately assists him into what position to promote maximal breathing in the thoracic cavity? - Correct Answer- Fowler's Position. Fowler's position promotes maximal breathing space in the thoracic cavity and is the position of choice when someone is having difficultly breathing. Ambulation - Correct Answer-Ability to walk from place to place independently with or without assistive device. A nurse is assisting a postoperative patient with conditioning exercise to prepare for ambulation. The nurse correctly instructs the patient to do which actions? - Correct Answer-Breathing in and out smoothly during quadriceps drills maximizes lung inflation. The patient should perform quadriceps 2 to 3 times per hour, 4 to 6 times a day, or as ordered. Push-ups are usually done three or four times a day and involve only the upper
body. The nurse should place the bed at the lowest position or use a foot stool for dangling. The nurse should also encourage the patient to be as independent as possible to prepare for return to normal ambulation and ADLs. A nurse is caring for a patient who is on bed rest following spinal injury. In which position would the nurse place the patient's feet to prevent footdrop? - Correct Answer- For a patient who has footdrop, the nurse should support the feet in dorsiflexion, and use a footboard or high-top sneakers to further support the foot. What is the proper procedure for using a cane? - Correct Answer-1.) Stand with weight distributed evenly between the feet and cane. 2.) Support weight on the stronger leg and the cane and advance the weaker foot forward, parallel with the cane. 3.) Support weight on weaker leg and cane and advance the stronger leg forward ahead of the cane. 4.) Move the weaker leg forward until even with the stronger leg and advance the can again as in step 2. The patient should keep the cane within easy reach and use it for support to rise safely from a sitting position. A 17-year-old patient has a fractured left leg, which has been casted. Following teaching from the physical therapist for using crutches, the nurse reinforces which teaching points with the patient? - Correct Answer-The patient should keep elbows at the sides, prevent pressure on the axillae to avoid damage to nerves and circulation, extend the injured leg to prevent weight bearing when rising from a chair, and advance the unaffected leg first when climbing stairs. A nurse working in a long-term care facility uses proper patient-care ergonomics when handling and transferring patients to avoid back injury. Which action should be the focus of these preventive measures? A.) Carefully assessing the patient care environment. B.) Using two nurses to lift the patient who cannot assist. C.) Wearing a back belt to perform routine duties. D.) Properly documenting the patient lift. - Correct Answer-A.) Carefully assessing the patient care environment. Preventive measures should focus on careful assessment of the patient care environment so that patients can be moved safely and effectively. Using lifting teams and assistive patient handling equipment rather than two nurses to lift increases safety. The use of a back belt does not prevent back injury. The methods used for safe patient handling and movement should be documented but are not the primary focus of interventions related to injury prevention. A nurse is assisting a patient who is 2 days postoperative from a cesarean section to sit in a chair. After assisting the patient to the side of the bed and to stand up, the patient's knees buckle and she tells the nurse she feels faint. What should the nurse do in this situation? - Correct Answer-If a patient becomes faint and knees buckle when moving from bed to chair, the nurse should not continue to move to the chair. The nurse should
lower the patient back to the side of the bed, pivot her back into bed, cover her, and raise the side rails. Assess the patients vitals signs and for the presence of other symptoms. Another attempt should be made with another staff member if vital signs are stable. Instruct the patient to remain in the sitting position on the side of the bed for several minutes to allow the circulatory system to adjust to change in position, and avoid hypo-tension related to a sudden change in position. A 49-year-old who injured his spine in a motorcycle accident is receiving rehabilitation services in a short-term rehabilitation center. The nurse caring for him correctly tells the aide not to place him in which position? A.) Side-lying. B.) Fowler's. C.) Sims'. D.) Prone. - Correct Answer-D.) Prone. The prone position is contraindicated in patients who have spinal problems because the pull of gravity on the trunk when patient lies prone produces a marked lordosis, or forward curvature of the lumbar spine. A nurse is using the Katz Index of Independence in Activities of Daily Living to assess the mobility of an 80-year-old hospitalized female patient. During the patient interview the nurse documents the following patient data: "Patient bathes self completely but needs help with dressing. Patient toilets independently and is continent. Patient needs help moving from bed to chair. Patient follows directions and can feed self." Based on the data, which score would the patient receive on the Katz index? - Correct Answer- The total score of this patient is 4. On the Katz Index of Independence in ADLs, one point is awarded for independence in each of the following: bathing, tolieting, dressing, transferring, continence, and feeding. Continence - Correct Answer-The ability to hold it all in. Self-control. Health History - Correct Answer-A collection of subjective information that provides information about the patient's health status. Physical Assessment - Correct Answer-A collection of objective data that provides information about changes in the patient's body systems. A _________ assessment with a health history and complete physical examination is usually conducted when a patient first enters a health care setting, with information providing a baseline for comparing later assessment. - Correct Answer-Comprehensive Ongoing partial assessment - Correct Answer-Follow-up assessment. Is one that is conducted at regular intervals during care of the patient. Concentrates on identified health problems to monitor positive or negative changes and evaluate the effectiveness of interventions.
Focused Assessment - Correct Answer-Conducted to assess a specific problem. Example.) A women is having abdominal pain, the nurse asks questions about urinary problems, bowel problems, allergies, and menstrual history during the health history and then assesses vital signs and abdominal structures during the physical assessment. Emergency Assessment - Correct Answer-A type of rapid focused assessment conducted when addressing a life-threatening or unstable situation. Example.) Assessment of the airway, breathing, and circulation when encountering a patient with traumatic injury as a result of a motor vehicle accident. Activities of daily living (ADLs) - Correct Answer-Self-care activities. Examples.) Eating, bathing, dressing, and toileting. Instrumental activities of daily living (IADLs) - Correct Answer-Those needed for independent living. Examples.) House keeping, meal preparation, management of finances, and transportation. Review of systems - Correct Answer-A series of questions about all body systems that help to reveal concerns or problems as part of the health history. Inspection - Correct Answer-The process of performing deliberate, purposeful observations in a systematic manner. Palpation - Correct Answer-Uses the sense of touch. The hands and fingers are sensitive tools that can assess skin temperature, turgor, texture, and moisture, as well as vibrations within the body (such as the heart) and shape or structures within the body. Percussion - Correct Answer-The act of striking one object against another to produce sound. The fingertips are used to tap the body over body tissues to produce vibrations and sound waves. Auscultation - Correct Answer-The act of listening with a stethoscope to sounds produced within the body. What are the four characteristics of sound assessed by auscultation? - Correct Answer- 1.) Pitch (Ranging from high to low) 2.) Loudness (Ranging from soft to loud) 3.) Quality (gurgling or swishing) 4.) Duration (Short, medium, or long) Body mass index (BMI) - Correct Answer-Is a ratio of weight to height. BMI is used as an initial assessment of nutritional status, and is an indicator of obesity or malnutrition. Waist circumference - Correct Answer-The measurement around a patient at the level of the umbilicus and is a good indicator or abdominal fat.
Cyanosis - Correct Answer-A bluish or grayish discoloration of the skin in response to inadequate oxygen. Jaundice - Correct Answer-A yellow color of the skin resulting from elevated amounts of bilirubin in the blood. Associated with liver and gallbladder disease, some types of anemia, and excessive hemolysis (break down of red blood cells). Pallor - Correct Answer-Paleness of the skin, often results from a decrease in the amount of circulating blood or hemoglobin, causing inadequate oxygenation of the body tissues. Echymosis - Correct Answer-Is a collection of blood in the subcutaneous tissues, causing purplish discoloration. Petechiae - Correct Answer-Are small hemorrhagic spots caused by capillary bleeding. If they are present, assess their color, location, and size. Diaphoresis - Correct Answer-An excessive amount of perspiration, such as when the entire skin is moist. Turgor - Correct Answer-The fullness or elasticity of the skin. Difficulty in lifting a skin fold may indicate ________. - Correct Answer-Edema (Excess fluid in the tissues). Bronchial sounds - Correct Answer-Heard over the larynx and trachea, are high-pitched, harsh blowing sounds, with sound of expiration being longer than inspiration. Bronchovesicular sounds - Correct Answer-Are heard over the mainstream bronchus and are moderate blowing sounds, with inspiration equal to expiration. Vesicular breath sounds - Correct Answer-Are soft, low-pitched, whispering sounds, heard over most of the lung fields, with sound on inspiration being longer than expiration. Adventitious breath sounds - Correct Answer-Abnormal sounds. Are not normally heard in the lungs but, if present, may be auscultated. The adventitious sounds result from air moving through moisture, mucus, or narrowed airways. These abnormal sounds also result from sudden opening of collapsed alveoli. Precordium - Correct Answer-The portion of the body over the heart and lower thorax, encompassing the aortic, pulmonic, tricuspid, and apical areas, and Erb's point. Observe for visible pulsations.
Bruits - Correct Answer-Are abnormal "swooshing or blowing" sounds heard over a blood vessel, caused by blood that is swirling in the vessel, rather than normal smooth flow. _________ involves gathering information about the health status of the patient. - Correct Answer-Health Assessment Nurses must consider patients within the context of _______, _______, and _______. - Correct Answer-Family, culture, and community. Nurses and other health care providers need to provide health care services in a ______, ______, and ______ manner. - Correct Answer-Sensitive, knowledgeable, and non-judgmental manner When conducting a nursing health assessment, it is important to consider and remain sensitive to the patients __________ and _________ needs. - Correct Answer- Physiological and psychological needs. _______ and ______ for the patient are primary concerns when conducting a health assessment. - Correct Answer-Privacy and respect. Health History - Correct Answer-A collection of data that provides a detailed profile of the patients health status. What are some examples of biographical data? - Correct Answer-Patients name, address, billing, insurance, gender, age, birth date, martial status, occupation, race, etc. The reason for _________ is a statement in the patients own words that describes the patients reason for seeking care. - Correct Answer-Requesting care. A patient's ______ health history may provide insight into causes of current symptoms. - Correct Answer-Past health history. Information about a person's _______ history will provide information about diseases and conditions for which an individual patient may be at increases risk. - Correct Answer-Family history. A ______ health assessment focuses on the effects of health or illness on a patient's quality of life, including the strengths of the patient and areas that need to improve. - Correct Answer-Functional health assessment. In a functional health assessment, the nurse assesses the patient's ability to perform ______. - Correct Answer-ADLs-Activities of daily living.
A _______ assessment is usually conducted in a head-to-toe sequence or a system sequence but can be adapted to meet the needs of the patient. - Correct Answer- Physical assessment. How do nurses prepare for physical examinations? - Correct Answer-Make the patient as comfortable and relaxed as possible. Be sure to use appropriate verbal and nonverbal communication techniques. The equipment used in a physical assessment should be _______, _______, and _______. - Correct Answer-Readily accessible, clean, and in proper working order. Equipment that will touch the patient should be warmed. A ______ is used to measure the patient's body temperature. - Correct Answer- Thermometer. A ______ is used to measure blood pressure. - Correct Answer-Sphygmomanometer. A _____ with height attachment is used to weigh the patient and measure height. - Correct Answer-Scale A ______ is used to measure blood pressure, and auscultate (listen to) the heart, lungs, abdomen, and cardiovascular sounds. - Correct Answer-Stethoscope. The ____ of the stethoscope is used to listen to low pitch sounds. (such as heart murmurs) - Correct Answer-Bell side The _____ of the stethoscope is used to listen to high-pitch sounds such as normal heart sounds, breath sounds, and bowel sounds. - Correct Answer-Diaphragm side. What is important to consider about a patient during positioning? - Correct Answer-The patients age, culture, health status, mobility, physical condition, energy level, and privacy. What are the four primary assessment techniques? - Correct Answer-1.) Inspection. 2.) Palpation. (method of feeling with fingers or hands) 3.) Percussion. 4.) Auscultation. Subjective data - Correct Answer-Data identified only by the person affected. (sensations, feelings, attitudes, beliefs, and perceptions). Objective data - Correct Answer-Data that is objective and measurable against a standard. (data obtained by accessing body systems, monitoring vital signs, obtaining physical measurements, and monitoring laboratory values).
How do you calculate the pulse deficit of a patient? - Correct Answer-By subtracting the radial pulse rate from the apical pulse rate. Radial pulse rate - apical pulse rate = pulse deficit. Excessive ________ of an artery sometimes will obliterate a pulse. - Correct Answer- Compression. Releasing pressure of the fingers slightly will allow blood flow through the artery. _________ pressure is calculated by subtracting the diastolic blood pressure from the systolic blood pressure. - Correct Answer-Pulse pressure. What is the size of a normal clitoris? - Correct Answer-2 cm long and 0.5 cm wide. An enlarged clitoris may indicate excess androgens and therefore should be reported to the primary health care provider. Hemiparesis - Correct Answer-Unilateral Paresis. Weakness of the entire left or right side of the body. Tremors - Correct Answer-Rhythmic purposeless movements of the extremities. Quadriplegia - Correct Answer-Paralysis of both arms and legs. At which site should the nurse position a stethoscope when assessing the apical pulse rate for an adult? - Correct Answer-At the apex of the heart. It is located at the end of the left ventricle, which is near the firth intercostal space and 3 to 4 inches to the left of the sternum at midclavicular line. A nurse is obtaining a patient's blood pressure. What is reflected by the diastolic blood pressure? - Correct Answer-Resting arterial pressure. The volume of ______ is computed by multiplying the stroke volume by the number of heart beats per minute. - Correct Answer-Cardiac output. Contraction of the left ventricle is reflected by the ________ pressure. - Correct Answer- Systolic pressure. _________ pressure is the difference between the systolic and diastolic pressures. - Correct Answer-Pulse pressure. The amount of circulating blood volume will influence the ______. - Correct Answer- Quality of the pulse. An increased circulating blood volume will result in a _______ pulse. - Correct Answer- Bounding pulse.
A decreased blood volume will result in a ________, thready pulse. - Correct Answer- Weak. Dyspnea - Correct Answer-Difficult or labored breathing. When a patient experiences an onset of a temperature, __________ should be avoided because it can increase body temperature. - Correct Answer-Shivering How many pounds are in 1 kilogram? - Correct Answer-2.2 pounds. A nurse is repositioning a patient in the right Sims' position. What action should the nurse implement when positioning this patient? - Correct Answer-Turn the body halfway between the lateral and prone position. Venous Stasis - Correct Answer-Condition of slow blood flow through the veins, usually in the legs. Ischial tuberosities - Correct Answer-look at image. What are some ways to position patients? - Correct Answer-Look at image. A blister over a bony prominence is a stage 2 _________. - Correct Answer-Pressure ulcer. Atrophy - Correct Answer-Decrease in the size of muscles. Lack of contraction of muscles that occurs with immobility results in __________. - Correct Answer-Atrophy. Observations of a stage IV pressure - Correct Answer-Tunneling under the epidermis; Full thickness skin loss. Thrombus - Correct Answer-Is the formation of a blood clot, inside a blood vessel, obstructing the flow of blood through the circulatory system. The prone position requires that the patient be repostioned after only ___ hour/s. - Correct Answer-1 hour; Orthostatic hypotension - Correct Answer-A form of low blood pressure in which a persons blood pressure falls when suddenly standing up or stretching. Dizzy spell/head rush. _________ are a person's temperature, pulse, respiration, and blood pressure. - Correct Answer-Vital signs
Body temperature - Correct Answer-Is the difference between the amount of heat produced by the body and the amount of heat lost to the environment measured in degrees. The primary source of heat in the body is __________. - Correct Answer-metabolism. Various mechanisms increase body metabolism, including _____ and ______. - Correct Answer-hormones and exercise. The _______ is the primary source of heat loss. - Correct Answer-Skin. Factors affecting body temperature. - Correct Answer-* Time of day.
Tachycardia - Correct Answer-A rapid heart rate. As the heart rate increase, ________ usually also increases. - Correct Answer-Cardiac output. Bradycardia - Correct Answer-Is a pulse rate below 60 beats/min in an adult. How is pulse amplitude assessed? - Correct Answer-By the feeling of the blood flow through the vessel. The pulse amplitude describes the quality of the pulse in terms of its _______ and reflects the strength of left ventricle contractions. - Correct Answer-Fullness. Pulse rhythm - Correct Answer-The pattern of the beats and the pauses between them. An irregular pattern of heartbeats is called _______. - Correct Answer-Dysrhythmia How do nurses assess the pulse? - Correct Answer-By palpating peripheral arteries or by auscultating the apical pulse with a stethoscope. A difference between the apical and radial pulse rates is called the _______. - Correct Answer-Pulse deficit. Respiration involves _____,_____, and ____. - Correct Answer-Ventilation, diffusion, and perfusion. ______ is the exchange of oxygen and carbon dioxide between the alveoli of the lungs and the circulating blood. - Correct Answer-Diffusion. _____ is the exchange of oxygen and carbon dioxide between the circulating blood and tissue cells. - Correct Answer-Perfusion. (foot is blue. oxygen not getting to extremities). Factors affecting respiratory rate and depth. - Correct Answer-Exercise, respiratory and cardiovascular disease, alterations in fluid, medications, trauma, infection, pain, and emotions. What is a normal respiratory rate for healthy adults? - Correct Answer-Healthy adults breathe about 12 to 20 times each minute. Eupnea - Correct Answer-Normal, unlabored respiration. Tachypnea - Correct Answer-An increased respiratory rate; May occur in response to an increased metabolic rate, such as when a person has a fever.
Bradypnea - Correct Answer-A decrease in respiratory rate, that occurs in some pathologic conditions. Apnea - Correct Answer-Refers to periods during which there is no breathing. What are the 5 vital signs? - Correct Answer-1.) Temperature 2.) Pulse 3.) Respiration 4.) Pulse Oximetry 5.) Blood Pressure When should a nurse asses vital signs? - Correct Answer-1.) Admission 2.) Every 4 hours 3.) If there is a change in the patients status 4.) Loss of consciousness 5.) When your patient leaves the floor 6.) Before certain medications 7.) Before and after activities What is considered an average temperature? - Correct Answer-97.0 to 99.5 degrees F. 36 to 37.5 degrees C. What is considered a average pulse rate? - Correct Answer-60 to 100 beats/min What is considered average respiration? - Correct Answer-12 to 20 breaths/min What is considered average blood pressure? - Correct Answer-120/ What is considered average pulse oximetry? - Correct Answer-95 to 100% What are the two types of body temperature? - Correct Answer-1.) Surface (shell) temperature. 2.) Core temperature. Core temperature - Correct Answer-Warmth in your tissues. Warmer than shell temperature. You can take a core temperature through the rectum or tympanic membrane. Sites to take a shell temperature. - Correct Answer-Skin, oral, or axillary. Thermoregulatory center in the _________ regulates temperature. - Correct Answer- Hypothalamus. The primary source of heat production is ________. - Correct Answer-Metabolism.
What are some sources of heat loss? - Correct Answer-Skin (primary source), Evaporation of sweat, warming and humidifying inspired air, and eliminating urine and feces. Factors that effect body temperature. - Correct Answer-1.) Carcadian rhythm (Sleep- wake cycle: Temp. higher during middle or day and lower a night). 2.) Age (Older: Temperatures rise slower; Babies: Temperatures rise quickly.) 3.) Gender (Females experience more body fluctuation due to hormones). 4.) Environment (Where you live). Pyrexia - Correct Answer-Fever; State of being in a fever. Hyperthermia can cause someone to have _______ or ______. - Correct Answer-Heat exhaustion or a heatstroke. (Heatstroke is worse). What can a patient with hypothermia have? - Correct Answer-Frostbite Physical Effects of a fever. - Correct Answer-1.) loss of appetite 2.) Flush/red/ hot skin 3.) Seizures/delirium 4.) Fatigue 5.) Dry skin-dehydration (thirsty) 6.) Muscle aches If a patient has a fever what happens to their respiration and pulse? - Correct Answer- The patient will experience an increase in respiration and pulse. If the fever is not fixed, their respiration and pulse will begin to decrease. What are some nursing interventions for reducing a fever? - Correct Answer-1.) Antibiotics (if it is a bacterial infection) 2.) Antipyretics (Tylenol, Ibuprofen, ASA (aspirin-do not use for children)) 3.) Increase fluids 4.) Simple carbs (Burn quick and break down easy). 5.) Cool packs or blankets. (never hot blankets). When a patient is experiencing Hyperthermia, they will have a _______ core temperature. - Correct Answer-Excessively high. When a patient is experiencing Hypothermia, they will have a ________ core temperature. - Correct Answer-Subnormal. (special thermometer used). When taking a patients temperature, what site is the first, second, and third choice to take it at? - Correct Answer-1.) mouth 2.) rectal 3.) axillary
Pulse - Correct Answer-The palpable bounds of blood flow noted at various points on the body-indicator of circulatory status. Cardiac output - Correct Answer-Volume of blood pumped by the heart during 1 minute. Stroke Volume - Correct Answer-The amount of blood ejected by the left ventricle in one contraction. The average cardiac output is ________. - Correct Answer-3.5 to 8 Liters Parasympathetic stimulation ______ heart rate. - Correct Answer-Decreases. Sympathetic stimulation _____ heart rate. - Correct Answer-Increases. Where is the most accurate place to check a patients pulse? - Correct Answer-Apical. (listen to it for 1 full minute). What can alter a patients pulse rate? - Correct Answer-1.) Medication. 2.) Pain. 3.) Activity. 4.) Emotions. If a patients stroke volume decreases, their heart rate is going to _______. - Correct Answer-Increase If a patient is experiencing a pulse of 100 to 180 beats/minute, they would have _______. - Correct Answer-Trachycardia If a patients pulse is below 60 beats/minute, they would be considered to have ______.
If respiration is irregular, or less than 12 or greater than 20, count for for ____ minutes. - Correct Answer-1 full minute. Count number of respiration's for ____ seconds then x 2 if regular. - Correct Answer- seconds. Trachypnea - Correct Answer-Increase in respiratory rate. (COPD, Excercise, pneumonia.) Orthopnea - Correct Answer-Breath best sitting up. Hyperventilation - Correct Answer-Increase rate in depth; Anxiety attack. Hypoventilation - Correct Answer-Decrease rate in depth; Overdose. Cheyne-Stokes respirations - Correct Answer-Death rattle; Body pools with fluid; Noisy, loud respiration's. Regular with periods of apnea. Happens when someone is actively dying. (hospice). Babies lungs are not completely developed so they should have _____ respiration. - Correct Answer-Abnormal. What does ABC's stand for? - Correct Answer-Airway, breathing, and circulation What can give a false pulse oximetry reading? - Correct Answer-Cold fingers, poor circulation, erratic heart rate, shaky hands, and constant movement. When does a nurse assess a patients pulse oximetry? - Correct Answer-Every 4 hours. If the patient is on Oxygen. If patient is being weaned off oxygen. Recheck 5 to 10 minutes after making a change in oxygen. If blood pressure goes _____, then pulse goes _____. - Correct Answer-Blood pressure goes up then pulse rate goes down. Blood pressure goes down then pulse rate goes up. Blood pressure - Correct Answer-The force of blood against the arterial walls. Systolic pressure - Correct Answer-Peak of maximum pressure when ejection occurs as the left ventricle in the heart contracts; forcing blood in to aorta. Diastolic pressure - Correct Answer-ventricle relax, exerting minimal pressure. Blood pressure is measured in _____. - Correct Answer-mmHg; Milometers of mercury.
Blood is made of ____, ____, and ____. - Correct Answer-Plasma, RBCs, and Fluids. Artherosclerosis - Correct Answer-Condition where plaque builds up inside a persons arteries.(can be genetic) Hypertension - Correct Answer-Blood pressure that is above normal for a sustained period; Systolic greater than 140 or diastolic greater than 90. What are hygiene practices? - Correct Answer-Caring for the skin, hair, nails, mouth, teeth, and perineal area. What may influence personal hygiene behaviors? - Correct Answer-Culture. Socioeconomic Class. Spiritual Practices. Developmental Level. Health state. Personal Preferences. Impairment of the _______ system can interfere with a patient's ability to perform tasks related to personal hygiene. - Correct Answer-Musculoskeletal When performing the physical assessment of the oral cavity, what should the nurse examine? - Correct Answer-1.) Lips 2.) Color of the gums and surface 3.) Teeth 4.) Tongue 5.) Hard and soft palate 6.) Oropharynx-Movement of the Uvula and condition of tonsil. Caries - Correct Answer-The decay of teeth with the formation of cavities. Caries result from failure to remove _______. - Correct Answer-Plaque Plaque - Correct Answer-An invisible, destructive, bacterial film that builds up on everyone's teeth and eventually leads to the destruction of tooth enamel. The major cause of tooth loos in adults older than 35 years of age is ________. - Correct Answer-Gum disease Gingivitis - Correct Answer-Is an inflammation of the gingiva, the tissue that surrounds the teeth. Periodontitis (periodontal disease) - Correct Answer-Is a marked inflammation of the gums that also involves degeneration of the dental periosteum (tissues) and bone.
The _______ attacks the fibers that fasten teeth to the gums and eventually attacks bone tissue. - Correct Answer-Tartar Halitosis - Correct Answer-A strong mouth odor or a persistent bad taste in the mouth,. Stomatitis - Correct Answer-An inflammation of the oral mucosa. Glossitis - Correct Answer-An inflammation of the tongue Cheilosis - Correct Answer-An ulceration and dry scaling of the lips with fissures at the angles of the mouth. Cerumen - Correct Answer-Wax; (ear) _________ is a condition characterized by itching and flaking of the scalp and may be complicated by the embarrassment it causes. - Correct Answer-Dandruff Alopecia - Correct Answer-Absence or loss of hair; Pediculosis - Correct Answer-Infestation with lice; Hemiplegia - Correct Answer-Paralysis of one side of the body. Debridement - Correct Answer-The removal of damaged tissue or foreign objects from a wound. Emaciated - Correct Answer-Abnormally thin or weak; especially because of illness or lack of food. External rotation - Correct Answer-Occurs when the entire leg is rolled outward from the body so that the toes point away from the opposite leg. Paresthesia - Correct Answer-An abnormal sensation, typically tingling or pricking, caused chiefly by pressure on or damage to peripheral nerves. Bounding pedal pulse - Correct Answer-A pulse that feels as thought your heart is pounding or racing. Heart palpitations. Unilateral Calf Edema - Correct Answer-Usually due to a local cause such as deep vein thrombosis. Enoxaparin - Correct Answer-Anticoagulant that is used to treat or prevent a type of blood clot called deep vein thrombosis, that can lead to a blood clot in the lungs.
Postural Hypotension - Correct Answer-Can occur when a patient has been lying or sitting for a prolonged period and quickly arises to an erect position. Blood pressure must drop to 20 points to be considered Postural Hypotension. Atelectasis - Correct Answer-Partial or complete collapse of the lung. Glascow Coma Scale (GCS) - Correct Answer-Measures neurological status. Braden scale - Correct Answer-Predicts pressure ulcer risks. Active range of motion exercises of the arms and legs help prevent ______. - Correct Answer-Contractures Which pulse site should not be assessed on both sides of the body at the same time? - Correct Answer-Carotid. Slight compression of both carotid arteries can interfere with blood flow to the brain. Exacerbation - Correct Answer-Is the period during chronic illness when symptoms reappear after a remission or absence of symptoms. Stridor - Correct Answer-A harsh or grating sound in the lungs; Activity Intolerance - Correct Answer-a nursing diagnosis that is defined by NANDA as a state in which an individual has insufficient physiological or psychological energy to endure or complete necessary or desired daily activities. Cachectic - Correct Answer-Generally ill health and malnutrition marked by weakness and excessive leanness (emacication). Surgical Asepsis - Correct Answer-Ensuring an environment is completely clean from all microorganisms. Hypoxia - Correct Answer-is a condition in which the body or a region of the body is deprived of adequate oxygen supply at the tissue level. Vitamin _____ is essential in clotting. - Correct Answer-Vitamin K. Body temperature is highest at what time? - Correct Answer-Between 8 p.m. and 12 a.m. Borborygmi - Correct Answer-Rumbling or gurgling noise made by the movement of fluid and gas in the intestines. Always document the _______ of a patient if they are not standing when taking blood pressure. - Correct Answer-position.
Sigmoidoscopy - Correct Answer-Colonoscopy Bell's Palsy - Correct Answer-paralysis of the facial nerve, causing muscular weakness in one side of the face. Which cranial nerves are used for sense of smell? - Correct Answer-Cranial nerve 1 Which cranial nerves are used for sense of hearing? - Correct Answer-Cranial nerve 8 Which cranial nerves are used for coordination of facial movement and reflex activity? - Correct Answer-Cranial nerves 5, 7, 9, and 12. Steps to measuring an adults orthostatic blood pressure. - Correct Answer-1.) Assist client into supine position. 2.) Wait 3-10 minutes, then measure the blood pressure. 3.) Assist client into sitting position with legs dangling. 4.) Wait 1-3 minutes, then measure blood pressure. 5.) Assist client into standing position. 6.) Wait 2-3 minutes, measure blood pressure. When blood pressure is taking by doppler, do you still use the cuff? - Correct Answer- Yes. When hemorrhaging, pulse rate ______. - Correct Answer-Increases. Expectorate - Correct Answer-cough or spit out phlegm from the throat or lungs. When cleaning a unconscious female patient, what is the most important location to clean? - Correct Answer-Under breasts and skin folds. What is a bating procedure for a patient that is incontinent? - Correct Answer-Use special perineal skin cleaners and moisture barriers. Iatrogenic - Correct Answer-of or relating to illness caused by medical examination or treatment. Escherichia Coli - Correct Answer-(E. coli) bacteria normally live in the intestines of healthy people and animals. Proper removal of PPE in order. - Correct Answer-1.) Remove gloves 2.) Remove goggles. 3.) Remove gown. 4.) respirator. Where is resident bacteria found? - Correct Answer-In creases of the skin.
Reye syndrome - Correct Answer-a life-threatening metabolic disorder in young children, of uncertain cause but sometimes precipitated by aspirin and involving encephalitis and liver failure. Hypocalcemia - Correct Answer-is a condition in which there are lower-than-average levels of calcium in the plasma. Paresthesias - Correct Answer-an abnormal sensation, typically tingling or pricking ("pins and needles"), caused chiefly by pressure on or damage to peripheral nerves. Pulse strengths - Correct Answer-3+ = Full or strong 4+ = Bounding 2+ = Normal/expected 1+ = Diminished/barely palpable.