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nur101 exam2

Quiz yourself by thinking what should be in each of the black spaces below before clicking on it to display the answer.
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Question
Answer
Jaundice   yellow (sclera) r/t impaired bilirubin  
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cyanosis   blue (mouth, nailbeds)decreased oxygen  
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erythema   redness (local or widespread)  
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Edema   excess fluid in tissue  
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trace edema 1+ edema 2+ edema 3+ edema 4+ edema brawny   not measurable 2mm 4mm 6mm 8mm warm, weeping, shiny, tight  
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turgor   elasticity (dehydration)  
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brisk turgor   normal  
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sluggish turgor   tenting of skin  
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symptom analysis "Old Carts"   onset, location, duration, characteristics, aggravating/alleviating systems, related symptoms, treatment, severity  
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Symptoms analysis "coldspa"   character (feel, sounds, smell, etc), onset, location, duration, severity, pattern, associated factors  
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Importance of nutrition and metabolic health pattern   deficiencies may explain other problems, fluid intake important, problems related to underweight/obesity, skin is line of 1st defense against infection, HC treatment may interfere with cellmatabolism,  
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essential nutrients   water, electrolytes, minerals, vitamins & protein for tissue building  
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daily calorie requirement for men/women   2800/2000  
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carbohydrates, fats, proteins & alcohol   help provide energy and support metabolic processes  
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nutrients   supply the body with necessary elements for growth, maintenance, and repair  
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macronutrients   carbohydrates, protein, fats  
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metabolism   process of producing and using energy within body cells  
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plays major role in metabolism   thyroid hormones  
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ways energy is used in the body   breathing, circulation, nervous system function  
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Basal Metabolic Rate (BMR)   the amount of energy required for essential life processes  
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BMR is measured by   when the body is physically, metabolically and emotionally at rest  
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BMR is influenced by these factors   activity, hormonal imbalance, temperature, stress, and illness  
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Metabolic processes   Anabolism, catabolism  
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anabolism   cell building, fat(adipose tissue),  
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catabolism   breaking down of cells and tissues  
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normal body mass index (BMI)   18.5-24.9  
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Nutritional processes   Ingestion, digestion, absorption, transport, metabolism  
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ingestion   nutrients taken into the gastrointestinal (GI) tract  
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digestion   breakdown of ingested nutrients to be absorbed by the body.  
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digestion process   begins in mouth (chewing saliva), peristalsis to stomach, to small intestines.  
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major digestive area   stomach  
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absorption   passage of digested food from gi tract to the blood or lymph circulation  
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place where most nutrients and electrolytes are absorbed   small intestines  
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transport   movement of nutrients across the cell membrane  
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metabolism   final process of nutrition. energy is produced and used in the body cells  
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Lab assessment for metabolism positive balance   more consumed than excreted  
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lab assessment for metabolism negative balance   intake less than output  
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lab tests   24 hour urine. bun blood test (albumin and protein)  
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1st line of defense   skin  
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functions of skin   protects underlying tissues and organs. also plays a role in maintaining temp, fluid/electrolyte balance, absorption, excretion, immunity, vit D synthesis, id of one's appearance.  
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layers of skin   epidermis, dermis, subcutaneous  
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epidermis   outer layer of skin  
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dermis   connective tissue and blood vessels  
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subcutaneous   connective tissue infiltrated with fat, blood vessels, nerves, and glands  
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Decubitus ulcers   pressure sores  
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stage 1 pressure sore   redness, blood stasis, warm to touch  
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stage 2 pressure sore   epidermal loss, possible damage to dermis  
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stage 3 pressure sore   fullthickness skin loss, sero-sanguinous or purulent drainage common  
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stage 4 pressure sore   full thickness, deep into connective tissue, muscle, bone. may have necrosis. may need debridement.  
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factors affecting wound healing   need adequate proteins, normal albumin, hemoglobin, hematocrit and transferrin levels  
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s/s of impaired wound healing   increased redness & swelling, pus formation, dehiscence (wound edges break loose), wound color changes, decreased granulation tissue  
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Lymphatic system/lymph nodes   act as filters of lymph fluid  
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location of lymph nodes   head, neck, breast, axilla, inguinal, clavicle & popliteal areas  
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lymphadenitis   inflammation of lymph nodes (painful)  
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lymphangitis   inflammation along the course of lymphatic vessel  
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lymphedema   lymph tissue swelling  
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largest endocrine gland   thyroid gland  
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thyroid gland controls   metabolic rate hormone production and secretion  
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hormones secreted by thyroid gland   t3(thyronine), t4, calcitonin  
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T3 hormone   increases BMR, increases chemical reaction rates, increase heat production, stimulates metabolism of essential nutrients, promotes human growth, short life span  
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T4 hormone   same function as T3, can be converted to T3, secreted in greater amounts, longer life span than T3  
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calcitonin   calcium metabolism  
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daily requirement of iodine   100-200 mcg from bread, salt, seafood, milk, eggs  
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parathyroid glands are located   posterior surface of thyroid gland  
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parathyroid glands regulate   calcium, phosphorus metabolism  
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signs of hyperthyroidism   exopthalmus (big eyes), weakness, fatigue, diaphoresis, tachycardia, chest pains, dysrhythmias, increased blood pressure, weight loss, increased appetite, diarrhea, or constipation, restless, nervous, insomnia, irritable, hyperactivity  
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signs of hypothyroidism   myxedema, decreased cardiac output and conduction, enlarged heart, decreased blood pressure, atherosclerosis (fat in blood vessels), increased cholesterol, lethargy, fatigue, slow speech, thick tongue, deep voice, weight gain, decreased appetite, constipa  
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other skin related problems   diabetes, liver, renal, cancer, fluid imbalance, impaired O2, peripheral vascular disease, skin infections  
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oral cavity   mucus mucosa, salivary glands, tongue, gums/teeth, palate  
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mucus mucosa   keeps mouth hydrated, aids in digestion, chemical barrier to trauma and infectious organisms  
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salivary glands   secrete up to 1500 ml/day, provides moisture, initiates starch breakdown  
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tongue   taste buds, moves food with saliva, initiates swallowing  
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palate   forms the roof of the mouth (hard and soft)  
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oropharnyx   moves food into the esophagus  
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questions for interviewing   diet, weight problems, ingestion problems, food and fluid intake nausea and vomiting, preferences, activity levels, psychosocial, cultural and personal influences, nutrition knowledge, physical changes  
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Physical Assessment - assess for:   subcutaneous fat, muscle mass, height, weight, skin integrity, hair, nails, oral cavity, abdomen, thyroid gland, body temp  
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skin assessment   color, pigment, moisture, temp, texture, thickness, turgor, mobility, hygiene, lesions  
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hair assessment   color, pigment, quantity, texture,distribution, hygiene  
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nail assessment   shape,configuration, color, lesions, thickness, cap refill  
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normal shape of nail   160 degree angle  
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abnormal findings of nails   clubbing, spooning, cyanosis  
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normal cap refill of nails   <3 seconds  
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