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Assessment Final
| Question | Answer |
|---|---|
| What are pack years and how do you calculate it? | Multiply the packs per day smoked by the number of years smoked. This is associated with some illnesses. |
| ETOHism: you should ask CAGE | C: Have you thought about CUTTING DOWN A: Have you ever been ANNOYED at someone's criticism of your drinking? G: Have you ever felt GUILTY about your drinking? E: Do you ever drink an EYE OPENER in the morning? |
| PQRST Symptom Analysis | Provocative: what makes it worst Quality: how does it feel Region: where is it Severity: pain levels & does it interfere with ADLs Timing: frequency and when it began |
| What is barrel chestedness and what can cause it? | When the AP-T ratio is 1:1 instead of 1:2 Can result from emphysema or COPD. The ribs will expand to help the lungs with capacity. |
| What are you looking for when you inspect a patient? | |
| Body shape, breathing, position, hands and feet, skin color, cough and voice | |
| What are the normal breath sounds? | Bronchial (by trachea) Bronchovesicular (both areas) Vesicular (alveolar sounds) |
| How many auscultation spots are there posteriorly? Anteriorly? | 9 posteriorly 5 anteriorly |
| Bulla | Large collection of fluid below the epidermis > 5mm Like a burn blister Bigger than a vesicle |
| Vesicle | Small collection of fluid below the epidermis <5mm Like a blister Smaller than a bulla |
| Nodule | Bigger than a papule ( > 5mm ) Circumscribed, palpable elevation Like a wart |
| Papule | Circumscribed, palpable elevation <5 mm Smaller than a nodule Like a mole |
| Macule | Flat, circumscribed alteration in skin color Like a freckle |
| Pustule | A visible collection of pus Like acne |
| Wheal | An area of dermal edema Fluid collection/ skin inflammation Like hives |
| Plaque | Palpable, raised, flat disc shaped solid Like psoriasis |
| Crust | Dried sebum & exudate Like impetigo residue |
| Scales | Accumulation of excess keratin Like dandruff |
| Ulcer | Circumscribed loss of tissue Like a pressure ulcer |
| Visceral pain | Pain in large organs |
| Deep somatic pain | Pain from tendons of vessels |
| Cutaneous pain | Localizable pain on the skin |
| Neuropathic pain | Pain of the nerves, usually caused by an infection of tissue |
| Referred pain | Pain that is felt in a different spot than the injury |
| When listening to a heart beat or a pulse, what are you interested in? | The rate and rhythm |
| How do you differentiate between a low grade and high grade fever | Less than 100.4 is low grade, more than 100.5 is high grade |
| Orthostatic blood pressure is often a sign of... | Dehydration |
| What are the components of an objective exam? | Inspection, palpation, percussion, auscultate |
| A + O x4 means what? | Alert and oriented to person, place, time & situation |
| What are the types of databases? | Complete, episodic, follow up, emergency |
| OLD CARTS | Onset Location Duration Character Alleviating/aggravating factors Radiation Timing Severity |
| HEEADSSS | Home Education/ employment Eating Activities with peers Drugs Sex Suicide/depression Safety |
| What is aphasia? | A language disorder that affects a persons ability to speak |
| What is dysarthria | Appropriate word choice and grammar, but sounds are distorted so speech is unintelligible |
| What is athetosis? | A slow, writhing, continuous and involuntary movement of the extremities |
| What is ataxia? | An impaired ability to coordinate movement. A staggering gait and postural imbalance |
| What kinds of things can you do in a cognitive function testing? | Orientation, attention span, recent & remote memory, general knowledge, new learning, judgement, thought process, thought content |
| What is the brainstems main function? | Responsible for physiological systems such as circadian rhythms and respiratory |
| Cranial Nerve I | Olfactory Test: have the patient smell something |
| Cranial Nerve II | Optic Test: ask them what color something is, or read a chart |
| Cranial Nerve III | Oculomotor Test: EOMI |
| Cranial Nerve IV | Trochlear Test: EOMI |
| Cranial Nerve V | Trigeminal Test: touch areas of the face and ask them where you are touching |
| Cranial Nerve VI | Abducens Test: EOMI |
| Cranial Nerve VII | Facial Test: smile, frown, and puff out cheeks |
| Cranial Nerve VIII | Vestibulocochlear Test: whisper test |
| Cranial Nerve IX | Glossopharyngeal Test: have them eat something, have them say Ah |
| Cranial Nerve X | Vagus Test: if they can speak and eat |
| Cranial Nerve XI | Accessory: have patient struggle up their shoulders against the force of your hand |
| Cranial Nerve XII | Hypoglossal Test: have them move their tongue around |
| What is the main function of the cerebrum | Memory and cognition |
| What is the main function of the neurological system? | Controls all behavioral and cognitive function of the body, and all involuntary and subconscious functions |
| What is the different between Cranial Nerve V and VII? | One is sensation and movement |
| What is the Romberg test? | Stand with feet together and have the patient close their eyes and make sure they aren't swaying or falling |
| What area of the brain do RAMs test? | Cerebellum |
| What is the difference between mood and affect? | Mood is affect over time? Affect is how a person's emotions appear to you |
| What is mental status? | A persons emotional and cognitive functioning |
| How is fluid intake mainly regulated? | Thirst |
| A fluid fluctuation of _____% can have adverse effects on health? | 5-10 |
| Why are the symptoms of mild dehydration so important to pay attention to? | Because it is the beginning signs of hypovolemic shock, which can lead to organ failure or even death |
| Why is a thrombosis so dangerous? | Because it can travel to the heart, lungs, or brain.. Leading to an MI, PE, or stroke |
| Pulse deficit | A difference in heart rate and pulse rate due to cardiac issues |
| Why should a patient walk around, especially after surgery? | Because a pressure gradient is created and venous blood is carried back to the heart. Deep breathing is good too to avoid atelectasis |
| What is the sound between s1 and s2 called? | Systole |
| AV valves | Tricuspid and mitral valves |
| What sounds are heard best at the AV valves? | s1 sounds |
| Abstract Reasoning | Judgment and hypothetical situations |
| Dynamic culture | Overtime a culture changes |
| Delirium | Has an acute onset with identifiable time of onset, it's usually treatable but medical attention is required immediately. |
| What is mental illness? | A syndrome characterized by clinically significant disturbances in a persons cognition, emotion, regulation or behavior that reflects a dysfunction in mental functioning |
| Mini cognition test | 3 item recall. Give the patient 3 items to remember and 20-30 minutes later, ask them to repeat the items. |
| LOC: alert | Follows instructions and responds appropriately to stimuli |
| LOC: lethargic | Drowsy, delayed responses, drifting off to sleep |
| LOC: stuporous | Requires vigorous stimulation for a response |
| LOC: comatose | Patient does not respond to any verbal/ painful stimuli |
| What are the nine abdominal regions? | Right hypochondriac, epigastric region, left hypochondriac Right lumbar region, umbilical region, left lumbar region Right iliac region, hypogastric region, left iliac region |
| Dementia | Slow, gradual onset. Time of onset is unclear and it's due to chronic disorders. It's progressive, but not immediate medical attention is needed. Loss of memory is common, especially for recent events |
| Steatorrhea | Floating stool because there is fat in the stool that wasn't absorbed properly |
| What are the 3 things that indicate constipation? | Infrequency passing stool 3 days without passing stool Hard or painful stools |
| Acholic | Clay-colored or grey stool |
| Eructation | Burping |
| Dysmennorhea | Severe pain with periods, to the point where ADLs are affected. |
| What kind of effect does general anesthesia have on the digestive system? | It stops peristalsis. |
| Legally, for what people is a nurse a mandated reporter for? | Children under 18, adults over 60, and people with disabilities |
| How do you factor in ice volume when documenting I&OS? | Divide it by 2 |
| 1 cup = _____ mL | 240 |
| 1 oz = _____ mL | 30 |
| 1 tbsp = ____ mL | 15 |
| 1 tsp = ____ mL | 5 |
| What is the average daily fluid output for an adult? | 30-40 mL/Hr Or 0.5-1 ml/kg/hr |
| How much fluid do adults usually lose in insensible loss? | 500-800 mL per day |
| What are some signs of fluid volume excess? | JVD, edema, bounding pulse, HTN, tachypnea, abdominal distention, dyspnea, crackles |
| What are some signs of fluid volume deficit? | Headache, flushed skin, dry skin, dry tongue, decreased urine output, dark yellow urine, sunken fontanels, increased HR, decreased BP, delayed CR, lightheadedness |
| What is dehydration? | A 1% or greater loss of body mass as a result of fluid loss. |
| What percentage of total body weight is fluid? | 52% (women) 60% (men) |
| SV Valves | aortic and pulmonic |
| What sounds are heard best at the SV Valves? | S2 sounds |
| What does JVD indicate? | Fluid volume excess or right sided heart failure |
| Physiological split | Most common regularly irregular pulse When we breathe in and hold our breath, pulse increases and we release it the pulse goes down |
| When is nystagmus seen in a normal person? | On an extreme lateral gaze |
| Vertigo | Sensation that a space is moving |
| Presyncope | Sensation that you're going to pass out |
| Lightheadedness | Foggy, heavy head |
| What is the main function of the cerebellum? | Responsible for balance and coordination |
| Kenesics | Where you put your body in space |
| Proxemics | How close you are to something |
| Xerostomia | Dry mouth that is due to reduced saliva flow, not thirst |
| Cheilitis | Cracked lips, especially at the corners of the mouth |
| Periodontal disease | The gums are swollen and are broken down. The root of the teeth are exposed. |
| Halitosis | Persistent bad breath |
| Glossodynia | Painful/ burning tongue |
| Goiter | Enlargement of the thyroid due to an imbalance of hormones |
| What is the most common site for nose bleeds | Kiesselbach plexus |
| What is the function of nasal turbinates? | To warm inhaled air |
| What is a polyp? | Abnormal growth on a mucous membrane |
| Where does hematopoiesis occur? | Bone marrow |
| What is the purpose of synovial fluid? | Acts as a lubricant to reduce friction |
| Synovial joints | Freely moveable joints. Meet in a cavity |
| Nonsynovial joints | Bones that are connected by fibrous tissue. Can be immovable or slightly moveable |
| Plump Line | Imaginary line that goes through joints vertically |
| What is effusion? | An accumulation of fluid where it should not be, typically in a joint |
| Crepitus | Cracking/movement of joints |
| Muscle testing | 5-0 for ROM |
| Dyspareunia | Painful intercourse |
| Amenorrhea | No periods, after pregnancy is ruled out |
| Menorrhagia | Excessive bleeding, either length of time or volume |
| Dysmenorrhea | Painful periods |
| Chelation | A way to remove lead from the blood |
| Lead exposure | Neurotoxin associated with a decrease in IQ, rate of growth |
| Arsenic exposure | Carcinogen, skin eruptions, associated with bladder, lung and skin cancer |
| Formaldehyde | Irritation to eyes, nose, throat and skin Associated with nose cancer |
Created by:
pBarbosa
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