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Assessment Final

QuestionAnswer
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