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Fundamentals One

Exam three review

QuestionAnswer
Where is the best site for the nurse to obtain the infant's pulse? The brachial or apical pulse
With a restless patient having a temperature of 102.2 F what is one of the first things the nurse should do? Place the patient on oxygen because during a fever cellular metabolism increases and oxygen consumption rises.
Which artery is most appropriate for assessing the pulse of a small child? Brachial or apical pulse
What mechanism transfers heat away by using air movement? Convection
What mechanism transfers heat from one object to another with direct contact? Conduction
What mechanism transfers heat from the surface of one object to the surface of another without direct contact? Radiation
What mechanism transfers heat energy when a liquid is changed to a gas? Evaporation
What do newborns wear to prevent heat loss? A cap
What lab value might help determine the amount of blood viscosity? The hematocrit or the percentage of red blood cells in the blood.
What medications can slow down the pulse rate? Negative chronotropic drugs such as digitalis, beta-adrenergic and calcium channel blockers.
Rectal temperatures are usually (higher/lower) than oral temperatures? Higher
Axillary temperatures are usually (higher/lower) than oral temperatures? Lower
What is the single most important thing individuals can do to prevent the spread of infection? Wash their hands.
What are the signs and symptoms of the inflammatory response? Swelling, redness, heat, pain or tenderness and loss of function in the affected body part.
A spike in postoperative infections is categorized as what type of health care associated infection? Exogenous infection
How does the posterior hypothalamus help control temperature? Initiates heat conservation mechanisms such as vasoconstriction
What is the name for the situation when heat loss mechanisms are unable to keep pace with excess heat production resulting in an abnormal rise in body temperature? Pyrexia
If the blood pressure is 140/60. What is the pulse pressure? 80
What happens in the ovulation phase? During ovulation, greater amounts of progesterone enter the circulatory system and raise the body temperature to previous baseline levels or higher.
The incidence of hypertension is greater in which type of patients? Diabetics, older adults and African Americans
What is the normal respiratory rate range for a newborn? 30 to 60 breaths per minute
What is the acceptable respiratory rate range for an infant (6 months)? 30 to 50 breaths per minute
What factors increase susceptibility of an individual to acquire an infection? Age, nutritional status, presence of a chronic disease, trauma and smoking.
What is a normal defense mechanism against infection in the respiratory tract? The cilia lining the upper airways of the lungs and normal mucous.
What effect might smoking have on the respiratory tract? Smoking may alter the defense mechanism of the respiratory tract and increase the patient's potential for infection.
What is a fever? An upward shift in the set point.
What is hyperthermia? An elevated body temperature related to the body's inability to promote heat loss or reduce heat production.
What effect does smoking have on a patient's blood pressure? Immediately increases BP and this increase can last for up to 15 minutes.
What effect does caffeine have on blood pressure? Caffeine increases blood pressure for up to 3 hours.
What is the average body temperature of older adults? 96.8 F (36C) Older adults have poor vasomotor control, reduced amounts of subcutaneous tissue and reduced metabolism.
What are the benefits of using a temporal artery thermometer? A temporal artery thermometer provides very rapid measurement and reflects rapid changes in core temperature.
Can the skill of temperature measurement be delegated? Yes, but the nurse is responsible for assessing changes in body temperature.
What are signs of systemic inflammation? Fever, malaise, anorexia, nausea and vomiting.
What are signs of local inflammation? Swelling, redness, heat, pain or tenderness and loss of function in the affected body part.
What is the function of the posterior hypothalamus? If it senses that the body's temperature is lower than the set point, the body initiates heat conservation mechanisms.
What does the anterior hypothalamus do? The anterior hypothalamus control heat loss by inducing sweating, vasodilation of blood vessels and inhibition of heat production.
What is cognitive learning? Includes all intellectual behaviors and requires thinking.
What is affective learning? Deals with expressions of feelings and acceptance of attitudes, opinions or values. Values clarification is an example.
What is psychomotor learning? Involves acquiring skills that require the integration of mental and muscular activity such as the ability to walk or use an eating utensil.
What is motivation? A force that acts on or within a person to cause the person to behave in a particular way.
What is an attentional set? The mental state that allows the learner to focus on and comprehend a learning activity.
What is self efficacy? Refers to a person's perceived ability to successfully complete a task.
How does intellectual growth move as a child matures? From the concrete to the abstract
Define patient's behavior in the stage of denial or disbelief. Avoids discussion of illness, withdraws from others, disregards physical restrictions; suppresses and distorts information given.
Define patient's behavior in the stage of anger. Blames and complains and often directs anger toward nurse or others.
Define patient's behavior in the stage of bargaining. Offers to live a better life in exchange for promise of better health.
Define patient's behavior in the stage of resolution. Begins to express emotions openly, realizes that illness has created changes and begins to ask questions.
Define patient's behavior in the stage of acceptance. Recognizes reality of condition, actively pursues information and strives for independence
What factors improve the education of an adult learner? Assess what the patient currently knows, wants to know, and setting mutual goals.
What must the nurse assess before teaching a patient? Determine information that is critical for the patient to learn.Ask questions that identify and define the patient's motivation. Determine the patient's physical and cognitive ability to learn.
Define health literacy. The cognitive and social skills that determine the motivation and ability of individuals to gain access to, understand, and use information in ways that promote and maintain good health.
What is the telling approach to teaching? Use the telling approach when teaching limited information. There is no opportunity for feedback with this method. Example: preparing a patient for an emergent diagnostic procedure.
What is the participating approach to teaching? The nurse and patient set objectives and become involved in the learning process together.
What is the entrusting approach to teaching? Provides the patient the opportunity to manage self care.
What is the reinforcing approach to teaching? Requires using a stimulus that increases the probability for a response. Feedback is a form of reinforcement.
How do you evaluate a patient's learning? By observing performance of expected learning behaviors under desired conditions.
What teaching techniques promote effective learning in the older adult? When information is paced slowly and presented in small amounts.
What is teaching? An interactive process that promotes learning.
What is learning? The purposeful acquisition of new knowledge, attitudes, behaviors and skills.
What controls body temperature? The hypothalamus located between the cerebral hemispheres.
What is an acceptable temperature range? 36 to 38 C (96.8 to 100.4 F)
What is diaphoresis? Visible perspiration
Where is the core temperature measured? Pulmonary artery, esophagus, urinary bladder and tympanic membrane.
What does a temporal artery measure? Cutaneous blood flow
What is a reliable noninvasive measure of core temperature? The temporal artery temperature
What is a fever? An elevated body temperature
What is hyperthermia? An elevated body temperature related to the inability of the body to promote heat loss or reduce heat production.
What is heat exhaustion? Occurs when profuse diaphoresis results in excess water and electrolyte loss.
What is hypothermia? Heat loss during prolonged exposure to cold overwhelms the ability of the body to produce heat.
What is stroke volume? Approximately 60 to 70 mL of blood enters the aorta with each ventricular contraction.
What is cardiac output? The volume of blood pumped by the heart during 1 minute, the product of stroke volume and heart rate of the ventricle.
What is tachycardia? An abnormally elevated heart rate above 100 beats/minute in adults.
What is bradycardia? A slow heart rate, below 60 beats/min in adults.
What is dysrhythmia? An abnormal rhythm
What is the advantage of a digit probe to measure O2 saturation? Are spring loaded and conform to various sizes
What is the advantage of an earlobe probe to measure O2 saturation? Have greater accuracy at lower saturations and are least affected by peripheral vasoconstriction
What is systolic pressure? The peak of maximum pressure in the aorta when ejection occurs.
What is diastolic pressure? When the ventricles relax, the blood remaining in the arteries exerts minimum pressure
What is pulse pressure? The difference between systolic and diastolic pressure
What does blood pressure reflect the interrelationship of? Cardiac output, peripheral vascular resistance, blood volume, blood viscosity and artery elasticity.
If you detect an abnormal rate while palpating a peripheral pulse, what is the next step? Assess the apical rate.
What is the pulse deficit? The difference between the apical and radial pulse
Created by: judypilcher