NUR3270 Final
____________________________________ - the negative aspects to a health condition and social or physical limitation.
Disability
_____________________________________ : Inability to perform calculations correctly
Dyscalculia
__________________________________: Involuntary repetition of a word or sentence spoken by someone else
Echolalia
____________________________ ___________________________ refers to the higher thinking processes that allow for flexibility, adaptability, and goal directedness
Executive function
______________________________ __________________________ determines the contents of consciousness, supervises voluntary activity, and is future-oriented.
Executive function
Tool to assess Self-care, sphincter control, transfers, locomotion, communication, and social cognition
FIM instrument
The ___________________ allows light to enter the eye and regulates the amount of light entering the eye at any given time
iris
Sensory perception Primary Prevention: Use of safety devices, Eye protection, hearing protection. Erythromycin in newborn's eyes to prevent infection. Proactive management of chronic conditions such as heart disease and diabetes Secondary Prevention (Screening) Collaborative Interventions: Surgery, Pharmacotherapy, Adaptive Methods (in relation to sensory variation)
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The sense of smell is controlled primarily by cranial nerve ______ (the _____________________ nerve) and plays a critical role in controlling the desire to eat and maintain a healthy nutritional state.
1 olfactory
Factors that affect sexuality: 1. 2. 3. 4.
1. biology 2. culture 3. family 4. society
The 4 major unites of the human brain: 1. 2. 3. 4.
1. cerebrum 2. diencephalon 3. brain stem 4. cerebellum
Lobes that each hemisphere of the cerebrum have 1. 2. 3. 4.
1. frontal 2. parietal 3. temporal 4. occipital
Phases of sexual response: 1. 2. 3. 4. 5.
1. motivation 2. arousal 3. genital congestion 4. orgasm 5. resolution
domains of cognitive function: 1. 2. 3. 4. 5. 6.
1. perceptual motor function 2. language 3. learning and memory 4. social cognition 5. complex attention 6. Executive function
what is a normal rate of breathing? ______ to _______
12 - 20
Adults up to 40 years of age should receive an eye exam at least every ____________ years.
2
Which rib does the angle of louis help to identify?
2nd
Cranial nerve:_____________________________________ Raising eyelids, extraocular movements, and papillary constriction
3 occulomotor
Cranial nerve: _________________________________ TrochlearDownward and inward eye movement
4 trochlear
___________________________________ is a state of disturbed consciousness and altered cognition with a rapid onset occurring over hours or a few days.
Delirium
These cochlear cells, by means of a complex series of mechanical wave activities, innervate impulses that are carried by nerve fibers to cranial nerve ___________ (the ______________________________ nerve) to the brain—where the cerebellum receives the signals and helps to maintain a sense of balance—and then further, reaching the auditory area of the temporal lobe for hearing.5
8 vestibulocochlear
Cranial nerve: _____________________________ Swallowing and speaking; sensation of nasopharynx, gag reflex, and taste to posterior third of tongue; secretion of salivary glands and carotid reflex; certain speech sounds and swallowing
9 Glossopharyngeal
To test for tactile fremitus, ask patient to say ______________ or _________________
99 1 to 1
Most cognitive tasks occur in which unit of the brain?
Cerebrum
Abnormal lungs sounds are referred to as ____________________________________________________
Adventitous
_______________________________: inability to write
Agraphia
_____________________________: impaired reading ability
Alexia
________________________________: Impaired ability to name places or objects; may have difficulty with sentence repetition, although comprehension and expression abilities are basically intact
Anomia
__________________________________________ (the fabrication of events to fill in memory gaps)
Confabulation
____________________________________ is the most frequent complication of hospitalization in the elderly population.
Delirium
_____________________________ ____________________________: Loss of ability to learn and recall new information on an ongoing basis
Anterograde amnesia
__________________________________ Language impairment at the conceptual level; may have difficulty with production or comprehension of language or both
Aphasia
__________________________ Inability to perform purposeful movements or manipulate objects, although sensory and motor ability is intact
Apraxia
____________________________________________: is a disease that occurs as a result of damage to the retina blood vessels in people who have diabetes
Diabetic retinopathy (DR)
Tool to assess activities of daily living?
Barthel index
__________________________ cognitive functioning includes perception, pattern recognition, and attention.
Basic
_________________________________________________________________: relate to personal care and mobility and include eating as well as hygienic and grooming activities such as bathing, mouth care, dressing, and toileting.
Basic Activities of Daily Living
BADLs syands for :
Basic activities of daily living
___________________________ aphasia: Impaired language expression characterized by nonfluent, labored speech; comprehension of language intact
Broca
Lung sound where expiration is longer than inspiration (3:2)
Bronchial
______________________________: course, loud; heard with consolidation (lung sounds)
Bronchial
_____________________________________: loud and high pitched, hollow quality (lung sounds)
Bronchial
Lung sound where the length of inspiratory phase is equal to expiratory phase.
Bronchiovesicular
_____________________________________________: blowing sounds, medium pitched (lung sounds)
Bronchiovesicular
Tool to asses Comprehensive functional and social health in adolescents
Dartmouth COOP Functional Health Assessment Charts
___________________________________ memory provides for long-term storage of large amounts of information.
Declarative
____________________________________ memory refers to the ability to consciously learn and recall information.
Declarative
Tool to assess Older adults: Cognitive function
Folstein Mini-Mental Status Examination (MMSE)
________________________________________- positive or neutral interaction between a person's health condition and ability to perform social or physical activities
Function
Tool to assess Older adults: Assesses IADLs
Functional Activities Questionnaire (FAQ)
Tool to assess adults Comprehensive functional and social health
Functional Independence Measure
_______________________________________________: the individual's ability to perform the normal daily activities required to meet basic needs; fulfill usual roles in the family, workplace, and community; and maintain health and well-being
Functional ability
Secondary prevention to impairment of functional ability
Functional assessment screening
_______________________________________________- is a person's private view of maleness and femaleness
Gender identity
______________________________________ is the feminine and masculine behavior exhibited
Gender role
tool to assess Older adults: Depression
Geriatric Depression Scale
_____________________________________________(unilateral): neglectInability to process and perceive stimuli on one side of the body or the environment despite intact senses; results in a deficit in attention and awareness to the affected side
Hemispatial
__________________________________________________ cognitive function is characterized by learning, comprehension, insight problem solving, reasoning, decision making, creativity, and metacognition
Higher-order
____________________________________________ memory or "attention span" allows memory of very small amounts of information, such as a series of six or seven digits, for a very short time
Immediate
_____________________________________ cognition signifies an observable or measurable disturbance in one or more of the cognitive processes resulting from an abnormality within the brain or a factor interfering with normal brain function.
Impaired
Bronchiovesiuclar sounds are heard best heard posteriorly between ______________________________. Best heard anteriorly over ____________________________________, 1st and 2nd intercostal spaces.
Scapulae Bronchioles
______________________________________ dementia occurs as a result of another disease process.
Secondary
__________________________ is the ability to perceive stimulation through one's sensory organs, such as the nose, ears, and eyes. This stimulation can be internal, from within the body, or external, from outside the body, and includes feelings of pain, temperature, and light.
Sensation
IADLs stands for
Instrumental Activities of Daily Living
_______________________________________________: more complex skills that are essential to living in the community. managing money, grocery shopping, cooking, house cleaning, doing laundry, taking medication, using the telephone, and accessing transportation
Instrumental Activities of Daily Living
_______________________________ cognition means that an individual exhibits cognitive behaviors that are considered to be within the range of normal for age and culture
Intact
______________________________ __________________________ refers to limitations of cognitive functioning and below-average intelligence (IQ score "70), in addition to limitations in conceptual skills, social skills, and activities of daily living. Identified before age 18.
Intellectual disability
__________________________ __________________________ a challenge in taking data signals in and then processing the information received.
Learning disability
The ________________________ system is another area of the brain that supports cognitive processing. Overlaps the cerebrum and diencephalon
Limbic
______________________________ is a degenerative eye disease that gradually damages the macula causing progressive loss of central vision.
Macular degeneration (AMD)
_______________________________________ broadly refers to the retention and recall of past experiences and learning
Memory
_________________________________________________: A 30-item, 10-minute questionnaire to measure cognitive impairment and progression of disease.
Mini-Mental State Examination (MMSE)
_____________________________________________ disorders refer to a group of disorders better known as dementia.
Neurocognitive
Tool to assess Children ages 2-12 years with physical disabilities: Assesses engagement in life activities—personal, family, social, and school parameters
Now, Growth & Development, Activities of Daily Living, General Health, Environment, and Documentation (NGAGED)
______________________ ___________________: Impaired ability to recognize visual forms
Object agnosia
The ___________________ __________________ communicates with the brain to produce vision
Optic nerve
_____________________________ is defined as the process by which we receive, organize, and interpret sensation
Perception
________________________________________________: a common circulatory problem in which narrowed arteries reduce blood flow to the limbs.
Peripheral artery disease (PAD)
___________________________________: Scratchy, high-pitched (lung sounds)
Pleural friction rub
_________________________________ dementia is irreversible and not secondary to another disease.
Primary
___________________________________ memory refers to the retention and retrieval of motor skills. It requires extensive training and provides for long-term storage of a moderate amount of information.
Procedural
___________________________________: Impaired ability to recognize faces
Prosopagnosia
________________________ ____________________________: Impaired ability to retrieve information from the past
Retrograde amnesia
_______________________________ _____________________________: can then be defined as the ability to receive sensory input and, through various physiological processes in the body, translate the stimulus or data into meaningful information.
Sensory perception
______________________________________________: Used with significantly cognitively impaired patients to assess lower levels of cognitive function; in other words, provides differentiating clarity among individuals who score less than 12 on the MMSE.
Severe Impairment Battery (SIB)
__________________________________________, defined as a person's sexual identity in relation to the gender to which they are attracted.
Sexual orientation
Rhonci lung sunds are best heard over _________________________ and _____________________________
Trachea Bronchi
True or false: The most significant cognitive changes occur from infancy through adolescence
True
True or false: Wheezing can be heard over all lung fields
True
Sensory receptor stimulation—conducted via cranial nerves __________, ____________ and ____________—is then transmitted to the nucleus of the solitary tract in the medulla of the brain and also sent to other areas within the brain. Messages about smell converge here, along with visceral sensory fibers from the esophagus, stomach, intestines, and liver, allowing taste and odor signals to initiate digestive activity.6
VII IX X
_______________________________ aphasia: Impaired comprehension of both written and verbal language, even understanding single words; speech fluent and person is unaware that words used are incorrect
Wernicke
_______________________________________ memory allows a small amount of information (approximately four chunks or meaningful units) to be actively maintained and manipulated for a short period of time.
Working
The nurse is using Piaget's theory to assess the cognitive development in a child. Which age most likely correlates a child who has reached a developmental milestone grasping the concept of conservation of numbers for the first time? a. 5 years b. 7 years c. 9 years d. 12 years
a
Which technique would be appropriate for clients who exhibit mild neurocognitive impairment? a. Reality orientation b. Behavioral confrontation c. Reflective communication d. Reminiscence group therapy
a
Which type of emergency assessment is the nurse performing when the nurse uses the "AVPU" mnemonic to assess a group of clients admitted with neurological injury after hiking at high altitude? a. Disability b. Exposure c. Breathing d. Circulation
a Disability assessment is a part of the primary survey that is done to assess the level of consciousness that may occur due to a neurological injury. In the mnemonic "AVPU," A indicates alert, V indicates response to voice, P stands for response to pain, and U indicates unresponsive.
Inspect the posterior thorax for : _________________________________ diameter
anterioposterior
Pleural friction rub sounds are heard best over ___________________________ lateral lung field
anterior
Which nursing objective would be essential for a client who is demonstrating manic-type behavior by being demanding and hyperactive? a. To ease the client's feelings of guilt b. To maintain a supportive, structured environment c. To point out reality through continued communication d. To broaden the client's contacts with other people on the unit
b
A client reports feeling nauseated immediately after cataract surgery. Which action would the nurse take? a. Provide some dry crackers to eat. b. Administer the prescribed antiemetic. c. Explain that this is expected after surgery. d. Encourage deep breathing until the nausea subsides
b An antiemetic will prevent vomiting; vomiting increases intraocular pressure and should be avoided
Which B vitamin deficiency will result in Wernicke encephalopathy? a. B3 (niacin) b. B1 (thiamine) c. B2 (riboflavin) d. B6 (pyridoxine)
b Severe deficiency of thiamine will result in Wernicke encephalopathy. Niacin deficiency causes pellagra. Riboflavin deficiency can result in cutaneous, oral, and corneal changes. Pyridoxine deficiency can progress to sideroblastic anemia, neurological disturbances, and xanthurenic aciduria, among other problems.
Which communication pattern is defined as confabulation? a. The flow of thoughts is interrupted. b. Imagination is used to fill in memory gaps. c. Speech flits from one topic to another. d. Statements are too loose to understand
b Using imagination to fill in memory gaps is the definition of confabulation; it is a defense mechanism used by people experiencing memory deficits
Which nursing intervention has the highest priority for a client who was in a motor bike accident and has a severe neck injury? a. Assessing for crepitus b. Assessing for bleeding c. Maintaining a patent airway d. Performing neurological assessment
c
Which action would the nurse take for an older client with Alzheimer disease who sleeps very little and becomes more disoriented from sleep deprivation? a. Shut the client's door during the night. b. Apply a vest restraint when the client is in bed. c. Leave a dim light on in the client's room at night. d. Administer the client's prescribed as-needed sedative medication.
c The nurse would leave a dim light on in the client's room at night. A small light in the room may prevent misinterpretation of shadows, which can heighten fear and alter the client's perception of the environment.
Which hearing disorder is more common in women than in men? a. Tinnitus b. Hyperacusis c. Otosclerosis d. Meniere disease
c Sex of the client may also influence the conditions associated with hearing loss. Women are at a higher risk of otosclerosis compared with men. Both men and women are equally at risk of some hearing loss due to conditions such as tinnitus and hyperacusis. Meniere disease is more common in men compared with women.
_______________________________ _____________________________ is primarily responsible for carrying out such functions, in which highly sophisticated neurons and neurotransmitters deliver information through complex networks.
cerebral cortex
____________________________________________: the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses.
cognition
Loss of the sense of touch is most often associated with ____________________________ disease; therefore treatment with surgery and/or medications are aimed at controlling or eliminating the underlying cause.
comorbid
The term ________________________ means "present at birth"
congenital
The use of an intranasal _________________________ spray is recommended to reduce or eliminate inflammation in the nasal and sinus passages. Further use of medications such as ___________________________________ is effective for the treatment and control of allergic rhinitis, which often causes chronic sinus congestion and polyposis.
corticosteroid antihistamines
_____________________________________________: fine crackling, high-pitched (lung sounds)
crackles
The nurse understands that clozapine is contraindicated in the client with which condition? a. Seizures b. Glaucoma c. Dysrhythmias d. Bone marrow depression
d Clozapine is an atypical antipsychotic medication that is contraindicated in clients with bone marrow depression.
The _________________________________ eye consists of three separate layers: the outer sclera and cornea; the middle layer, which houses the choroid, ciliary body, and iris; and the innermost layer, which is the retina
internal
When the information relates to specific events, the terminology used is __________________________ _________________________ memory.
declarative episodic
______________________________ _____________________________ memory is the memory of knowledge, words, and facts
declarative semantic
The size and weight of the brain and number of neurons _______________________________ with aging.
decrease
______________________________ can be the initial symptom of life-threatening problems such as pneumonia, urosepsis, or myocardial infarction.
delerium
During a ________________________________ state, the individual experiences a dulled awareness of the environment and a reduced ability to focus, sustain, and shift attention. Speech is rapid, rambling, and/or incoherent. Sudden, intense emotional swings, hallucinations, vivid dreams, and delusions may also occur. Restlessness is common, although in some cases activity may be reduced. Memory and judgement are impaired, disorientation may occur.
delirious
A number of underlying conditions can lead to ___________________________ such as dehydration, electrolyte imbalances, fever, hypoxia, sleep deprivation, adverse effect of medications, and illicit drug use
delirium
Alzheimer disease (AD), Parkinson disease, human immunodeficiency virus (HIV) infection, frontotemporal, Lewy body type, traumatic brain injury, vascular, substance induced, Huntington disease, prion disease are subtypes of ________________________________________ that are classified as etiologic subtypes of NCDs
dementia
_________________________________ is a functional limitation with regard to a particular activity
disability
_____________________ AMD: blockage of retinal capillaries, allowing retinal cells in the macula to become ischemic and necrotic
dry
Population at highest risk for impairment of sensory perception
elderly
The ________________________ ________________________ opens to allow airflow when one is chewing and swallowing
eustachian tube
The middle ear is an air-filled space that is located in the temporal bone. It is connected to the throat/nasopharynx by the____________________________ _________________________, whose primary function is to equalize air pressure on both sides of the eardrum.
eustachian tube
The eyelid, conjunctiva, lacrimal gland, and eye muscles all comprise the _________________________________________ eye, which helps to regulate and control the visual input as well as protect the eye, aid with tear production, and move the eye when desired
external
___________________________ cognitive disorders affect a single area of cognitive function. These disorders may be associated with an NCD or may be seen independently.
focal
_______________________________ refers to a disadvantage in filling a role in life relative to a peer group.
handicap
Sexual intimacy throughout the life span is equally important for sexual ____________________
health
The __________________________________________ (a part of the limbic system) plays a significant role in committing information to long-term memory.
hippocampus
Cognitive ____________________________ refers to deficits in intellectual functioning
impairment
Functional _____________________________________ - the physical abnormality that underlies limitations caused by some type of disease process
impairment
_________________________________________- refers to a problem with a structure or organ of the body
impairment
Located in the center of the retina, the _________________________ is responsible for giving us clear vision and the ability to see fine detail. Although it is small, it enables us to see "20/20" and to see our world in color.
macula
_________________ cognitive impairment demonstrate a greater reduction of cognitive function than expected for an individual's age and education, but it does not interfere with functional ability.
mild (cind) cognitive impairment, not dementia
Chest land marks
nipples angle of louis suprasternal notch costal angle clavicles vertebrae
Sensation and perception occur throughout the body. Level of function ranges from _____________________________________ to _____________________________________-.
optimal function to impairment
Functional _____________________________________ - the actual daily activities carried out by an individual
performance
vesicular lung sounds are heard best over the _________________________________________ of lungs
periphery
____________________________: transforms light impulses into electrical impulses that are transmitted to the optic nerve
retina
________________________________: coarse, low pitched; may clear with cough (lung sounds)
rhonchi
Crackles are best heard over _________________________________ and ________________________________ lung bases.
right and left
__________________________: is a broad term that refers to all aspects of being sexual
sexuality
_____________________________ includes: a person's thoughts and feelings about the body a sense of femaleness and maleness romantic and erotic attachments toward others attitudes toward sexual functioning.
sexuality
The accessory muscles of breathing: ________________________________ _____________________________ _______________________________
sternocleidomastoid trapezius abdominal
____________________________________ vibrations caused by vocal cords
tactile fremitus
A person's gustatory system, or sense of taste, involves various cranial nerves and is directly related to the ability of the mouth and tongue to detect the chemicals—also referred to as __________________________—in the foods that we eat
tastants
taste signals are initiated by chemical stimulation of the taste buds, located primarily on the surface of the ________________________ and in the __________________
tongue pharynx
Lung sound where the inspiratory phase is 3x longer than expiratory phase
vesicular
_________________________________________: Soft, breezy, and low-pitched (lung sounds)
vesicular
____________________________________ ________________________________ is the capacity to comprehend, retain, and use visual representations and their spatial relationships.
visuospatial cognition
_________________ AMD: growth of new blood vessels in the macula, which have thin walls and leak blood and fluid
wet
_____________________________________: Whistling, high-pitched bronchus (Lung sounds)
wheeze
The 12 Activities of Daily Living According to the Roper-Logan-Tierney Model of Nursing
• Maintaining a safe environment • Breathing • Communication • Mobilizing • Eating and drinking • Eliminating • Personal cleansing and dressing • Maintaining body temperature • Working and playing • Sleeping • Expressing sexuality • Dying
The five senses:
• Vision • Hearing • Taste • Smell • Touch