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NUR162 - Quiz 4
| Question | Answer |
|---|---|
| Skin: The patient has a skin problem (rash, lump, itching, dryness, lesions); what do you ask | How long have you had this problem |
| prn | As needed |
| NPO | nothing by mouth |
| hs care | night time care (hours of sleep) |
| Skin: What do you document in the nursing history with regard to skin | The pt's typical hygein practices and any complaints |
| Which pt's are at risk for oral problems | Those who are seriously ill, comatose, dehydrated, confused, depressed, or paralyzed, no oral intake of fluids, pt's w/ nasogastric tubes, or oral airways in place, or who have had oral surgery |
| What does an assessment of the oral cavity include | teeth, tongue, salivery glands, note any unusual odors, assess the adequacy of mastication and swallowing |
| Foot problems are commonly seen related to what diseases | Diabetes millitus and peripheral vascular disease |
| What does bathing a patient facilitate | Inspection of the skin, and fosters patient relationship |
| What are the priorities of partial a.m. care | Toilet, teeth, washing the face, dressing and grooming |
| What should you pay careful attention to when examining the skin | Cleanliness, color, texture, temperature, turgor, moisture, sensation, vascularity, and any lesions |
| When documenting the condition of the skin (or any skin problems) what should be included | Details of exactly what is observed or palpated, including appearance, texture, size, location or distribution, and characteristics of any findings. |
| Is "Ensure linens are changed daily" an example of a nursinng intervention | yes |
| What is a diaphoretic pt, and what would you do for them | A pt with perspiration, you would change clothing and bed linins |
| What is the difference between gingivitis and periodontis | Gingivitis is an inflammation of the gingiva (the tissue that surrounds the teeth). Periodontis is a marked inflammation of the gums that also involves degeneration of the dental periostem and bone. |
| What is the difference between plaque and tartar | Plaque is an invisible bacterial film. Tartar is the formation of hard deposits at the gum lines |
| Gait | inspection of the skin, and fosters patient relationship |
| stomatitis | inflammation of the oral mucousa |
| glossitis | inflammation of the tongue |
| cheilosis | an ulceration of the lips (reddened fissures at the angles of the mouth) usually caused by vitamin B deficiencies |
| What are some reasons for providing back massage | Relaxes muscle tension and promotes relaxation. Provides nurse with opportunity to observe skin for signs of breakdowns. Improves circulation. May improve sleep quality, decrease pain, distress, and anxiety. |
| Can bathing be considered physical activity | Yes, it promotes circulation, serves as musculoskeletal exercise, stimulates the rate and depth of respirations |
| Pediculosis | Infestation with lice |
| cerumen | ear wax |
| How often would artifficial tear solution be given if the patient cannot blink | every 4 hours |
| Would you massage the legs for treatment of embolism | No, b/c it could loosen the embolism |
| What do you check for regularly on a pt who is using antiembolism stockings | check for redness, blistering, swelling, and pain |
| 39-What do bones provide storeage for | minerals, salts, and fat |
| 39-Where are short bones found | Wrist and ankle--short bones contribute to movement |
| condyloid joint | wrist joint, knuckles |
| fibrous joints | immovable (synarthrosis), No joint cavity; fibrous connective tissue between bones. Ex: sutures of the skull |
| Cartilaginous | Slightly movable (amphiarthrosis), No joint cavity; cartilage between bones. Pubic symphysis; joints between bodies of vertebrae |
| Synovial | freely movable (diarthrosis). Joint cavity containing synovial fluid. Gliding, hinge, pivot, condyloid, saddle, ball-and-socket joints |
| Orthopedics | the correction or prevention of disorders of body structures used in locomotion |
| tonus | term used to describe a state of slight contraction--the usual state of skeletal muscles |
| contracture | permanent contraction of a muscle (pt's on prolonged bedrest are at risk for contracture) |
| What do the postural reflexes do | They work as indicators telling the brain what a body part, limb, etc… is doing (location, head position) or where things are in our environment in relation to self, or that a muscle is stretched too far |
| What does the proprioceptor or kinesthetic sense postural reflex do | Informs the brain of a location of a limb or body part as a result of joint movements stimulating special nerve endings in muscles, tendond, and fascia |
| Why is any condition that restricts joint mobility a big concern | Because having any condition that restricts joint mobility has potentially crippling effects |
| What are examples of some diseases that result in a decreased amount of oxygen being available at the cellular level, decreasing the tolerance of physical activity | anemia, angina, cardiac arrhythmias, heart failure, and COPD |
| What does a negative nitrogen balance result in | muscle wasting, and decreased physical energy for movement and work (anorexia nervosa and certain cancers) |
| For minor orthopedic problems following exercise what should be done | R. I. C. E. Rest, Ice (to minimize pain and adema), Compression (with and elastic bandage), and Elevation (to further reduce edema) Then advice pt to contact dr to diagnose the extent of the injury |
| How often should a patient who is prescribed bed rest change position to maintain correct body alignment | every 2 hours |
| Should reddened areas of the body be massaged | no |
| What is Fowler's positition | AKA the semisitting position, the head of the bed is at 45 to 60 degrees. This position is used to promote cardiac and respiratory functioning b/c abdominal organs drop in this position given the thoracic cavity maximal space. |
| How often should range-of-motion be done with a pt, how is it performed | Twice a day. Each exercise is carried out 2-5 times. Many of the exercises can be carried out when the pt is being bathed and become part of that proceedure. Encourage routine tasks to help put certain joints thru range-of-motion. |
| What is the primary cause of injury for nurses | patient-handling |
| How do you measure to fit a pt for axillary cruches | With pt in bed measure to the heel with walking shoes on, and add 1 inch. Or measure the fold to the anterior of the axilla diagnally to a point 10 - 15 cm (4-6 inches) from the heel allowing 3 finger widths from the top of the crutch to the axilla |
| What controls the cyclic nature of sleep | Two systems in the brainstem--the reticular activating system (RAS) and the bulbar synchronizing region are believed to work together |
| What are the 2 main stages of sleep | REM and nonREM (NREM). NREM makes up about 75% of total sleep and has 4 stages. Stages 1 (5%--a transition from wakefullness to sleep) and 2 (50%)are light sleep. Stages 3(10%) and 4(10%) are deep sleep (also called Delta sleep) |
| sleep requirements: infants | 14-20 hours |
| how long does a typical sleep cycle last | 90-100 minutes--most people experience 4-5 a night |
| sleep requirements:growing children | 10-14 hours |
| What is the recommended amount of sleep for adults | 7-9 hours |
| Asthma attacks occur less frequently during which sleep stage | stage IV NREM |
| Chest pain occurs and gastric secretions increase during which stage of sleep | REM |
| Epilectic seizures occur more frequently during which sleep stage | NREM |
| Why should sedative-hypnotics never be taken with alcohol | b/c alcohol potentiates their effect |
| What are some illnesses associated with sleep disturbances | Peptic ulcers, coronary artery disease, epilepsy, liver failure, encephalitis, and hypothyroidism |
| Nociceptive pain | from injury, surgery |
| neuropathic pain | injury to or abnormal functioning of peripheral nerves or the CNS |
| psychogenic pain | a physical cause of the pain cannot be identified |
| cuatneous source of pain | sunburn, cut |
| somatic source of pain | deep, is profuse or scattered and originates in the tendons, ligaments, bones, blood vessels and nerves |
| visceral source of pain | poorly localized and originates in body organs in the thorax, cranium, and abdomen |
| What is it called when a pain is resistant to therapy and persists despite a variety of interventions | intractactable |
| What are some physiologic responses to pain | Increased BP, Pulse, and respiratory rates. Pupil dilation, muscle tension and rigidity, Pallor, Increased adrenalin output, Increased blood glucose |
| What is transduction | The activation of pain receptors |
| What are nociceptors | The peripheral nerve fibers that transmit pain--pain receptors |
| What do cells release when they are damaged which excites nerve endings | histamine |
| Lactic acid is believed to do what in damaged tissue | lower the threshold of nerve endings to other stimuli or to excite nerve endings and cause pain |
| What are other substances that are released that stimulate nociceptors | Bradykinen (vasodilatora), Prostaglandins (add'l pain stimuli to CNS), and Substance P (sensitizes receptors on nerves to feel pain and increases the rate of firing of nerves |
| What is it called when neuromodulators bind to specific opioid receptor sites (which can happen throughout the CNS) and block the release or production of pain transmitting substances | modulation |
| which neuromodulator inhibits the release of substance P from the afferent terminals of neurons | Enkephalins (they also weaken endorphins) |
| Which neuromodulator has the most potent analgesic effect | Dynorphin-- they strengthen the effect of endorphins |
| What are endorphins | Powerful pain-blocking chemicals that have prolonged analgesic effects and produce euphoria. They are produced at various points in the CNS pathway |
| What are some examples of an affective response to pain | psychological responses--crying, anxiety, fatigue, hopelessness |
| Who needs a pain assessment | EVERYONE |
| What should be assessed for a patient who is in pain | Description of the pain: duration, location, quantity and intensity, how long has the pain been going on, is it intermittent. What makes it worse or better. How is the pain affecting pt's lifestyle. Note behavioral and physiological responces. |
| Opioids can cause respiratory depression, what is used to referse this effect | Narcan, it's an opioid antagonist--it's administered intravenously very slowly. Within 1-2 minutes the pt usually opnes eyes and is able to respond to the nurse. |
| What are adjuant drugs | Drugs that typically have a use other than pain reduction but are also used to enhance the effect of opioids by providing additional pain relief. They may also reduce side effects of prescribed opioids or lessen anxiety about pain. |
| Name 3 commonly used adjuvants | Corticosteroids, anticonvulsants, and antidepressants |
| What is the recommended treatment for chronic pain | Regular ATC administration of analgesics (Long-acting controlled-release oral morphine or oxycodone or use of a fentanyl patch have been proven effective for chronic cancer pain) |
| Why is giving oral medications preferred if possible | Because they last longer (have a longer half life) |
| REM sleep is what portion of a persons sleep. | 20-25% |
Created by:
cspearsall