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NR 304 Final
| Question | Answer |
|---|---|
| what causes hypotension? | MI shock hemorrhage vasodilation Addison disease |
| smoking effect on BP | narrows arteries & hardens walls. increases BP |
| acute pain responses | guarding grimacing stillness diaphoresis moaning agitation change in vitals restlessness |
| stage 1 PI | nonblanchable redness skin intact |
| stage 2 PI | partial thickness loss blister loss of epidermis or dermis superficial/shallow |
| stage 3 PI | full thickness loss subcutaneous, granulation tissue crater |
| stage 4 PI | exposed muscle, bone, tendon slough/eshcar tunneling |
| manifestations of hypothyroidism | fatigue cold intolerance Non-pitting edema/puffiness coarse hair, eyebrows, skin |
| manifestations of breast cancer | inverted nipple, discharge immovable tumor constantly growing non-tender mass (upper quadrant) |
| jaundice in light skin pts | sclera, hard palate, mucous membranes |
| jaundice (dark skin) | hard n soft palate, palms |
| pallor (dark skin) | ashen gray, yellow brown |
| cyanosis (light skin) | dusky blue , nail beds |
| cyanosis (dark skin) | dark but dull, conjuctiva, oral mucosa, and nail beds |
| errythema (dark skin) | palpate for warmth, purplish tinge |
| late manifestations of rheumatoid arthritis | ulnar deviation/drift |
| spinal deformities associated with OA | kyphosis limited ROM |
| risks for osteoporosis | PMD white women smaller frame lack of physical activity lack of estrogen |
| what is RA | chronic - synovial membranes becomes inflamed autoimmune |
| manifestations of RA | swann neck/boutenierre deformities bilateral joints affected acute flareups |
| this arthritis has morning stiffness & is relieved by movement | RA |
| what is OA | noninflammatory, progressive disease joints begins to break down - bone 2 bone asymmetrical joint involvement |
| what causes OA | wear/tear injury constant weight bearing obesity |
| is movement a relieving or aggravating factor to OA? | Aggravating night pain |
| deformities with OA | heberden and bouchard's nodes |
| UTI symptoms in older adults | |
| clinical manifestations of urinary retention | inability to pass urine, leads to UTI |
| symptoms of BPH | frequency, urgency, hesitancy, straining, weak stream |
| objective data of BPH | symmetric nontender enlargement prostate feels smooth, rubbery or firm |
| positive romberg sign | loss of balance when the eyes are closed |
| FAST | face drooping, arm weakness, speech difficulty and time to call 911 |
| Glasgow scale 15 | normal |
| a glasow coma scale of a 7 or less indicates: | coma |
| hemorrhagic stroke symptoms | severe headache sudden LOC focal seizures nasuea/vomitting |
| ischemic stroke symptoms | unilateral facial droop, weakness, drift difficulty w/ speech sudden dizziness loss of balance cloudy vision |
| CN II | optic - visual fields |
| CN I | olfactory - smell |
| CN VII (7) | symmetry |
| CN VIII (8) | |
| CN XII (12) hypoglossal | light, tight and dynamite |
| CN XI (11) spinal accessory nerve | raise shoulders, turn head against resistance |
| CN III, IV & VI (3, 4,6) oculomotor trochlear, and abducens | PERRLA, cardinal field gaze |
| CN V (5) trigeminal | sensory (cheek test w cotton ball) / motor (palpate masseter clench teeth) |
| assessments of the Peripheral vascular system | cap refill clubbing pulses |
| alleviating factors of venous insufficiency | elevation, lying, walking |
| mechanisms of venous return | contracting skeletal muscles pressure gradient by breathing intraluminal valves ensures 1 way flow |
| chronic venous symptoms | edema varicosities weeping ulcers at ankle |
| varicose veins manifestations | aching heaviness in calf easy fatigaility restless legs burning throbbing/cramping |
| dilated tortous veins aka ___ | varicose veins |
| DVT manifestations | sudden onset of intense, sharp, deep muscle pain |
| chronic arterial symptoms | ABI cool, pale skin diminished pulses pallor on elevation |
| 1+ pitting | mild, slight indentation, no swelling |
| 2+ [pitting | moderate, indentation subsides rapidly |
| 3+ pitting | deep pitting, leg looks swollen, indentation stays a while |
| 4+ pitting | very deep pitting, indentation lasts a long time, grossly swollen and distorted |
| hypoactive bowel sounds | decreased motility due to inflammation late bowel obstruction paralytic ileus after abdominal sx |
| intestinal bowel obstruction manifestations | restlessness distended abdomen hyperactive bowel sounds tenderness to palpation hypovolemic shock |
| s/s of intestinal bowel obstruction | vomitting fever absence of stool/gas colicky pain due to dehydration/sepsis |
| positive murphy sign | Inflamed gallbladder. Tenderness. Inspiratory arrest |
| diagnostic results associated with intestinal/bowel obstruction |
Created by:
Mariahj25
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